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tt^M^  J62  Principles  and  pract 


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^cijool  of  Bental  anb  0val  ^uv^erp 


LIBRARY  OF 

Dr.  carl  F.  W.  BODECKER 

1846-1912 

The  gift  of 

Dr.  Henry  and  Dr.  Charles  Bodecker 

1929 


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in  2010  with  funding  from 

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c^^^u^ 


Principles  and  Practice 


OF 


Filling  Teeth. 


BY 


C.  N.  JOHNSON,  MA,  LD.S.,  D.D.S., 

I'KOFKSSOR    OF    OPKRATIVK    DENIISTRV    IN    THE   CHICA(;<J    COLLEGE 
OE  DENTAI,  SUKGEKV. 


WITH  II.LUSTRATIONS. 


I'm  I.ADKLI'H  lA  : 
'I'liE  S.  S.   Willi  I.  Demai,  Manueaciukinc;  Comtany. 

I.O.N  1J(J\  : 

Cl.AiDirs  Ash  iS:  So.ns   (Limited). 

1900. 


x\s'i'^^ 


Copyright,  1900,  by  C.  N.  Johnson. 
Entered  at  Stationers'  Hall,  London. 


CONTEI^TS. 


PAGE 

INTRODUCTORY 5 

CHAPTER  1 9 

Deposits  ox  the  Teeth.  Kinds  of  Deposits. — Salivary  Calculus. — 
Serumal  Calculus. — Stains  on  the  Teeth.  Removal  of  Deposits.  Re- 
moval of  Salivary  Calculus. — Instruments  for  this  purpose. — Technique 
of  the  Operation. — Removal  of  Stains  from  the  Teeth. — Instructions  fo 
Patients  as  to  the  Care  of  the  Teeth. 

CHAPTER  II 31 

Dental  Caries. 

CHAPTER  III 44 

Examination  of  the  Teeth  for  Caries.  Appliances  for  Exam- 
ining the  Teeth. 

CHAPTER  IV 47 

Exclusion  of  Moisture  During  Operations.  Kinds  of  Rubber 
Dam. — Size  of  Dam. — Punching  the  Holes  in  Rubber  Dam. — Rubber- 
Dam  Clamps. — Kinds  of  Clamps. — Clamps  for  Molars  and  Bicuspids. — 
Cervical  Clamps  for  Buccal,  Labial,  or  Lingual  Cavities. — Ligatures  — 
Manner  of  Applying  the  Dam  in  the  Difterent  Locations  in  the  Mouth. — 
Applying  the  Dam  for  Operations  on  Buccal,  Labial,  or  Lingual  Cavi- 
ties.— Application  of  Dam  in  Difficult  Cases. — L^se  of  Napkins  and  Cot- 
ton Rolls  for  Maintaining  Dryness  During  Operations. — Napkins. — Rolls. 
CHAPTER  V 79 

Cla.ssification  and  Preparation  of  Cavities.  Cavity  Prepa- 
ration. Simple  Proximal  Cavities.in  Incisors  and  Cuspids. — Separating 
Teeth. — Detail  of  Cavity  Formation. — General  Considerations. — Proxi- 
mal Cavities  in  Anterior  Teeth  Involving  the  Incisal  Angle. — Detail  of 
Cavity  Formation. — General  Considerations. — Proximal  Cavities  in  Bi- 
cuspids and  Molars. — Simple  Proximal  Cavities  not  Involving  other 
Surfaces. — Proximo-Occlusal  Cavities  in  Bicuspids  and  Molars. — The  In- 
terproximal Space. — Separating  the  Teeth. — Details  of  Cavity  Formation. 
— General  Considerations. — Buccal,  Labial,  or  Lingual  Cavities. — Occlu- 
sal Cavities  in  Bicuspids  and  Molars. — The  Treatment  of  Softened  Dentine 
in  Deep-Seated  Cavities. — Hypersensitive  Dentine. 
CHAPTER  VI 130 

Filling-Materials.  Gold  and  its  Combinations'. — Gold  and  Plati- 
num.— Gold  and  Tin. — Gold  and  Iridium. — Amalgam. — Tin. — Cements. 
— Gutta-Percha. — Inlays. 

CHAPTER  VII 164 

Gold.  Cohesive  and  Non-Cohesive  Gold. — Annealing  Gold. — Difter- 
ent Forms  of  Gold.— Crystal  Golds. 

CHAPTER  VIII 174 

Mallets  and  Mallktino.  Tlie  Hand  Mallet. — The  Automatic 
Mallet. — The  Rapid  Mallets. — Hand  Pressure. — Protection  to  the  Peri- 
dental Membrane  in  Malleting. 

8 


4  CONTENTS. 

PAGE 

CHAPTEK  IX 185 

The  Introductiox,  Condensation,  and  Finishing  of  Gold  Fill- 
ings IN  THE  Different  Classes  of  Cavities.  Simple  Proximal  Gold 
Fillings  in  Incisors. — Pluggers. — Finishing  Proximal  Fillings  in  Incis- 
ors.— Proximal  Fillings  in  Anterior  Teeth  Involving  the  Incisal  Angle. 

Fillings  in  Proximo-Ocelusal  Cavities  in  Bicuspids  and  Molars. — The 

Matrix. — Disto-Occlusal  Fillings  in  Left  Lower  Bicuspids  and  Molars. — 
Pluggers. — Finishing  Fillings. — Disto-Occlusal  Fillings  in  Eight  Lower 
Bicuspids  and  Molars. — Disto-Occlusal  Fillings  in  Upper  Bicuspids  and 
Molars. — Mesio-Occlusal  Fillings  in  Bicuspids  and  Molars. — Occlusal 
Fillings  in  Bicuspids  and  Molars. — Buccal,  Labial,  or  Lingual  Fillings. 

CHAPTEK  X 221 

Manipulation  of  Platinum  and  Gold  in  Filling  Teeth. 

CHAPTEB  XI 22a 

Manipulation  of  Tin  and  Gold. 

CHAPTER  XII 227 

Manipulation  of  Amalgam.     Method  of  Packing  Amalgam. 

CHAPTER  XIII 231 

Manipulation  of  Cements. 

CHAPTER   XIV 234 

Manipulation  of  Gutta-Percha. 

CHAPTER  XV 235 

Making  Inlay  Filling.'^.     Porcelain  Inlays. — Gold  Inlays. 

CHAPTER  XVI 241 

Pulp-Capping.  Materials  for  Capping  Pulps.— Method  of  Capping 
Pulps. 

CHAPTER  XVII • • ;  •  •  •    247 

Destruction  of  the  Pulp.  Destroying  the  Pulp  with  Arsenic. — 
Removing  the  Pulp  with  Cocaine. — Removal  of  the  Pulp 

CHAPTER  XVIII • 254 

Filling  Pulp-Canals. 

CHAPTER   XIX 258 

The  TreatiMent  of  Pulpless  Teeth.  Treatment  of  Pulpless  Teeth 
where  the  Canals  have  long  heen  Exposed  to  the  Fluids  of  the  Mouth,  but 
where  th^reis  no  Fistulous  Opening.— Treatment  of  Pulpless  Teeth  having 
a  Fistulous  Opening  on  Gum.— Opening  into  Filled  Teeth  in  which 
Pulps  have  Died,  but  Lain  Dormant.— Management  of  Pulpless  Teeth  in 
Anterior  Part  of  Mouth  to  Prevent  Discoloration.— Bleaching  Teeth. 

CHAPTER  XX 

The  Management  of  Children's  Teeth.  Management  of  the 
Deciduous  Teeth.— Treatment  of  Exposed  Pulps  in  Deciduous  Teeth.— 
Treatment  of  Abscessed  Deciduous  Teeth.— The  Managem€nt  of  Perma- 
nent Teeth  in  Childhood. 


269 


INTRODUCTORY. 


The  problem  of  preventing  or  controlling  caries  of  the  teeth  is 
one  which  enters  very  materially  into  the  health,  longevity,  and 
happiness  of  the  hnman  race.  Apparently  we  are  not  yet  able  to 
prevent  decay,  and  it  thus  becomes  imperative  that  we  study  the 
Ijest  means  of  checking  and  controlling  it.  When  caries  occurs 
on  any  surface  of  a  tooth  the  dentist  should  study  carefully  the 
•conditions  which  brought  it  about,  and  should  aim  in  his  operations 
so  to  change  those  conditions  that  caries  will  not  be  likely  to  recur. 

Too  many  practitioners  are  in  the  hal)it  of  following  their  work 

<lay  after  day  in  a  thoughtless,  slip-shod  manner,  without  due  con- 

.sideration  of  the  principles  which  should  underlie  all  operative 

procedures,  and  without  a  proper  study  of  the  relations  of  cause 

and  effect.     When  failures  occur,  as  they  do  in  the  hands  of  all 

practitioners, — some  more,  some  less, — the  most  profitable  lesson 

is  not  always  learned  thereby.      Xo  dentist  should  allow  himself 

to  pass  over  any  failure,  whether  his  own  or  another's,  without 

carefully  studying  the  particular  reasons  for  that  failure  and  the 

problems  which  must  be  solved  to  avoid  a  repetition  in  the  future. 

With  the  clearness  of  vision  which  should  eventually  result  from 

this  kind  of  study  the  practitioner  will  be  better  equipped  to  serve 

his  patrons,  and  his  failures  will  grow  perceptibly  fewer.     If  all 

•rlentists  wonM  bring  to  their  \v<.i-k  a  due  regard  for  this  form  of 

observation,  it  wouM  ;m1<1  ni:itcriiilly  to  the  pcnniincncc  of  dental 

service. 

5 


6  IJN^TRODIJCTORY. 

In  the  consideration  of  the  present  subject  the  principal  aim  will 
be  to  direct  attention  to  some  of  the  causes  of  failure  in  filling 
teeth,  and  to  offer  suggestions  relative  to  possible  improvement  in 
methods  of  procedure.  In  doing  this  no  originality  of  treatment 
is  claimed.  The  thought  of  the  profession  in  recent  years  has 
been  too  active  along  these  lines  for  any  one  individual  to  claim 
much  in  the  way  of  originality.  But  some  of  the  recent  advances 
in  practice  would  seem  to  need  systematizing,  and  most  of  them 
require  emphasizing.     This  is  the  present  aim. 

The  plan  is  to  treat  the  various  topics  as  nearly  as  practicable  in 
the  order  of  their  performance  in  the  mouth;  to  give  in  detail  the 
consecutive  steps  of  the  operation,  and  to  say  something  of  the 
technique  of  the  subject.  This  latter  is  considered  to  be  of  very 
great  importance,  but  it  is  a  matter  quite  difficult  of  intelligent 
treatment.  The  proper  selection  and  use  of  instruments  has  much 
to  do  with  the  effectiveness  of  our  work  and  the  comfort  of  our 
patients,  but  the  personal  equation  of  each  individual  operator 
enters  so  prominently  into  the  question  that  it  is  difficult  to  lay 
down  rules  for  all  to  follow.  Then,  again,  there  is  such  a  varia- 
tion in  patients  with  regard  to  their  toleration  of  different  instru- 
ments that  it  is  not  always  judicious  to  use  the  same  instruments  in 
the  same  way  on  all  patients.  We  must  study  carefully  this  sus- 
ceptibility of  our  patients,  and  in  all  cases  where  it  will  not  inter- 
fere with  the  perfection  of  our  work  we  should  respect  their 
preference.  Some  individuals  will  submit  to  the  use  of  hand 
instruments,  such  as  excavators  and  chisels,  with  better  grace  than 
they  will  to  the  engine,  while  very  many  prefer  the  smooth,  light 
touch  of  a  rapidly-revolving  bur  to  the  grating,  rasping  sensation 
of  an  excavator.  In  the  routine  practice  of  operating  there  are 
some  stages  of  the  work  where  the  engine  is  clearly  indicated,  and 
some  where  hand  instruments  must  be  used,  but  the  predominance 


INTRODUCTORY. 


of  the  use  of  either  may  in  certain  instances  be  determined  by  the 
patient.  Xot  that  we  should  in  any  sense  allow  patients  to  dictate 
to  us  how  we  shall  operate,  but  that  we  may  often  profitably  study 
their  varying  susceptibilities  to  the  impressions  made  upon  them 
by  different  instruments,  and  govern  our  manipulation  somewhat 
thereby. 

Much  in  the  way  of  prejudice  may  be  overcome  by  the  invaria- 
ble use  of  keen,  sharp  instruments  and  a  dextrous,  careful  method 
of  manipulation.  This  applies  as  w^ell  to  the  engine  as  to  hand 
instruments.  The  dentist  should  cultivate  the  utmost  delicacy  of 
touch,  so  as  to  impress  upon  his  patient  at  all  times  the  fact  that 
he  is  giving  the  least  possible  discomfort  commensurate  with  effec- 
tive work. 

The  system  of  technique  here  suggested  is  not  presented  as 
being  applicable  to  all  operators  or  all  patients.  It  is  not  even 
claimed  that  it  is  the  best  system,  but  merely  that  it  is  an  attempt 
to  formulate  a  definite  and  consecutive  method  of  procedure  in  the 
performance  of  many  of  our  operations,  which  in  the  past  seem, 
for  the  most  part,  to  have  been  performed  without  method  and 
without  svstem. 


Principles  and  Practice  of  Filling  Teeth. 


CHAPTER    L 

DEPOSITS  ON  THE  TEETH. 

The  first  duty  of  the  dentist  when  a  patient  a})plies  to  him  for 
attention  to  the  natural  teeth  is  the  thorough  removal  of  all 
deposits,  provided  the  patient  is  not  suffering  pain.  In  every 
instance  where  there  is  suffering  the  manifest  duty  of  the  profes- 
sional man  is  to  relieve  it  at  once  if  possible,  no  matter  in  what 
form  it  may  jjresent  itself;  but  after  this  is  accomplished,  and 
before  any  tilling  operations  are  undertaken,  the  mouth  should  be 
put  in  as  nearly  a  hygienic  condition  as  may  be  secured  by  the  ut- 
most cleanliness.  It  is  too  often  the  case  that  operators — some  of 
them  with  a  brilliant  record  as  skillful  manipulators — seem  to  ig- 
nore this  important  procedure,  and  hasten  to  the  insertion  of  fill- 
ings in  teeth  covered  with  calculus.  It  matters  not  how  beautiful 
or  how  perfect  an  operation  may  be  under  these  conditions,  the 
work  should  never  be  considered  as  ideal  dental  service,  ^o  suc- 
cessful architect  ever  builds  a  house  without  first  looking  well  to 
the  foundation,  and  no  surgeon  of  repute  will  proceed  to  operate 
upon  a  wound  without  at  least  making  the  surrounding  ])arts  as 
liealtliv  i[<  may  lie  in  aih'aiicc.  i)('iitists  ai'c  iKtt  living  \\\)  tn  the 
highest  i)0ssibilities  of  their  art  when  they  fail  to  consider  the  im- 
])ortance  of  maintaining  the  tissues  around  the  teeth  in  a  state  of 
health,  and  this  cannot  be  done  short  of  a  careful  removal  of  all 
extraneous  material  which  may  be  found  adherent  to  the  teeth. 
It  is  not  within  the  pnjvincc  of  the  present  work  to  go  minutely 
into  the  pathology  of  this  subject,  and  yet  it  would  seem  desirable 


10 


PEINCIPLES   AND  PRACTICE   OF  FILLING  TEETH. 


to  briefly  indicate  some  of  the  deleterious  effects  produced  by  de- 
posits when  allowed  to  remain. 

The  encroachment  of  calculus  along  the  neck  and  root  of  a 
tooth,  if  left  unchecked,  results  in  an  absorption  of  the  gum,  the 
peridental  membrane,  and  even  the  alveolar  process,  so  that 
finally  the  support  of  the  tooth  is  destroyed,  and  it  is  allowed  to 
topple  over  and  fall  out.  It  is  estimated  by  many  observant  prac- 
titioners that  more  teeth  are  lost  as  the  result  of  diseased  conditions 
in  the  tissues  surrounding  them  than  from  decay  of  the  teeth 
themselves;  and,  if  this  be  true,  it  is  very  important  that  dentists 
should  pay  especial  attention  to  the  agencies  calculated  to  bring 
about  such  conditions.  It  is  undeniably  a  fact  that  calculus  in  a 
mouth  subject  to  its  continual  formation  will,  if  allowed  to 
accumulate,  sooner  or  later  work  the  destruction  of  the  teeth. 


Fig.  3. 


Fig.  1. 


Fig.  2 


Figs.  1,  2,  and  3  illustrate  some  extreme  cases  of  calculus 
formation  about  the  teeth.  Figs.  1  and  2  show  the  mesial  and 
distal  aspects  of  two  lower  incisors  with  calculus  attached,  actual 
size.  Fig.  3  is  a  mass  of  calculus  detached  from  the  buccal  sur- 
face of  an  upper  molar.  The  patient  applied  to  her  dentist  for 
examination  relative  to  some  "growth"  which  she  said  was  forming 
in  her  mouth,  and  the  result  was  the  removal  of  this  piece  of 
calculus;  here  reproduced  in  two  views,  actual  size.  It  must  be 
apparent  that  in  the  specimens  shown  the  teeth  need  not  neces- 
sarily have  been  lost  if  early  attention  had  been  given  to  these 
deposits.  There  was  not  the  slightest  indication  of  caries  upon 
any  of  them,  and  it  is  safe  to  conclude  that  had  the  patients  sought 


DEPOSITS    ON    THE    TEETH.  11 

and  obtained  proper  dental  service  in  the  initial  stages  of  the 
affection  the  teeth  might  have  been  preserved  for  many  years  of 
usefulness.  It  is  true  that  in  these  particular  cases  the  patient 
had  failed  to  apply  to  the  dentist  in  time  to  accomplish  anything, 
through  an  ignorance  of  the  significance  of  the  deposits,  and  yet 
there  would  seem  to  be  many  instances  where  the  neglect  is  not 
entirely  traceable  to  the  patient.  It  should  be  the  office  of  the 
dentist  not  only  to  perform  operations  on  the  teeth,  but  to  so 
educate  those  who  come  under  his  charge  that  the  general  public 
shall  be  made  familiar  with  conditions  so  readily  understood  as 
these,  and  so  manifestly  self-evident  when  attention  is  once  called 
to  them. 

KINDS  OF  DEPOSITS. 

Deposits  are  usually  classified  under  three  kinds,  salivary  calcu- 
lus, serumal  calculus,  and  green  stain,  though  from  an  operative 
point  of  view  the  latter  would  seem  to  be  widely  distinguishable 
from  the  other  two.  it  is  not  a  deposit  of  appreciable  bulk,  and 
it  is  entirely  different  in  character,  both  as  regards  its  deleterious 
effects  and  the  methods  to  be  employed  in  its  removal.  Nor 
would  it  seem  to  be  altogether  appropriate  to  limit  the  term  to 
"green"  stain.  There  are  other  stains  on  the  teeth  besides  those 
of  a  green  color,  and  they  should  not  be  ignored  in  considering 
the  subject. 

Salivary  Calculus. 

This,  as  its  name  implies,  is  chiefly  a  deposit  from  the  saliva. 
The  solid  constituents  of  this  secretion,  which  are  normally  held 
in  solution  during  its  progress  from  the  gland  to  the  mouth,  be- 
come so  affected  by  the  change  of  environment  on  entering  the 
oral  cavity  as  to  be  precipitated  in  the  form  of  calculus  on  the 
teeth.  This  being  true,  we  should  naturally  expect  to  find  the 
most  extensive  deposits  upon  the  surfaces  of  the  teeth  lying  nearest 
to  the  openings  of  the  salivary  ducts,  a  fact  borne  out  by  clinical 
observations.  The  usual  points  of  initial  deposit  of  salivary  calcu- 
lus are  upon  the  lingual  surfaces  of  the  lower  incisors,  opposite  the 
openings  of  the  ducts  from  the  sublingual  and  submaxillary  glands, 


12  PRIXCIPLES   AXD  PRACTICE   OF  FILLING  TEETH. 

and  uj)on  the  buccal  surfaces  of  the  upper  molars,  which  are 
copiouslv  bathed  in  the  parotid  saliva.  This  must  not  imply  that 
these  are  the  only  surfaces  subject  to  the  deposition  of  salivary 
calculus.  There  is  no  surface  of  any  tooth  exposed  to  the  fluids 
of  the  mouth  which  may  not  accumulate  this  deposit,  provided 
there  is  an  absence  of  friction  on  that  surface. 

The  full  function  of  mastication  would  seem  to  be  one  of  the 
most  effectual  natural  processes  in  limiting  the  deposition  of 
salivary  calculus,  it  being  plainly  evident  to  an  observant  operator 
the  moment  he  looks  into  a  mouth  where  mastication  is  confined 
to  one  side.  It  will  invariably  be  found  that  the  teeth  on  the 
unused  side  will  present  an  altogether  neglected  appearance,  and  if 
there  is  a  predisposition  to  the  formation  of  calculus  they  will  be 
almost  completely  covered  with  it,  even  over  the  occlusal  surfaces. 
A  striking  object-lesson  may  be  given  patients  as  to  the  necessity 
of  keeping  the  teeth  in  active  and  uniform  service  by  calling 
attention  to  the  difference  in  appearance  of  the  teeth  on  the  two 
sides,  and  impressing  them  with  the  fact  that  wherever,  for  any 
reason,  thorough  mastication  is  impracticable  the  deficiency  should 
be  supplied  by  substituting  artificial  friction  mth  the  tooth-brush. 
The  demand  for  friction  relates  as  well  to  the  gums  as  to  the 
teeth,  it  being  very  exceptional  to  find  a  healthy  condition  of  the 
gums  in  any  locality  not  subjected  to  full  functional  use. 

This  question  of  giving  the  teeth  and  gums  adequate  employ- 
ment should  be  carefully  studied  by  operators,  and  its  necessity 
forced  upon  the  attention  of  patients.  It  is  the  keynote  of  health 
in  the  mouth,  as  elsewhere  in  the  human  body,  and  it  should  be 
the  prime  function  of  the  dentist  to  keep  the  oral  tissues  healthy. 
It  is  infinitely  a  higher  aim  to  prevent  disease  than  to  cure  it,  and 
if  dentists  take  this  matter  seriously  at  heart  they  can  accomplish 
much  in  this  direction.  A  critical  study  should  be  made  of  the 
conditions  present  in  every  mouth  coming  under  the  operator's 
attention,  and  a  careful  note  made  of  the  various  landmarks  of 
neglect.  The  results  of  this  neglect  must  invariably  be  pointed 
out  to  the  patient,  and  an  impression  made  in  such  a  manner  that 
it  cannot  be  ignored.     If  the  dentist  thereby  fails  to  enlist  the 


DEPOSITS    OX    THE    TEETH.  IJJ 

co-opei-atioii  of  liis  patient,  it  is  only  common  justice  to  at  once 
absolve  himself  from  responsibility  for  the  ultimate  saving  of  the 
teeth.  This  will  nsnally  bring  the  patient  to  a  proper  realization 
of  the  true  relation  existing  between  operator  and  patient,  and 
will  at  least  establish  an  intelligent  understanding  between  them. 

In  character  salivary  calculus  may  vary  from  a  soft  granular 
mass,  easily  removed  and  disintegrated  with  an  instrument,  to  a 
hard,  dense,  and  almost  flint-like  consistence.  This  difference  in 
density  relates  chiefly  to  the  rapidity  with  which  it  is  formed  and 
the  length  of  time  it  is  allowed  to  remain  in  the  mouth.  When 
it  is  rapidly  deposited  and  of  recent  formation  it  is  comparatively 
soft,  but  seems  to  grow  progressively  harder  if  left  undisturbed. 
The  color  also  varies  materially  in  different  specimens,  from  a 
yellowish  gray  to  a  black,  the  former  usually  being  associated 
with  rapid  and  recent  formations,  while  the  latter  is  ordinarily 
confined  to  cases  of  long  standing.  In  some  mouths  the  yellowish 
gray  remains  almost  indefinitely,  so  that  the  question  of  color  is 
not  entirely  one  of  age;  and  yet  in  specimens  of  extensive  accumu- 
lation, such  as  those  illustrated,  it  will  usually  be  found  that  the 
portion  nearest  the  tooth,  and  which  accordingly  has  been  longest 
in  place,  is  much  darker  than  that  more  recently  formed  upon  the 
surface. 

The  present  reference  to  color  relates  to  a  staining  of  the  calcu- 
lus itself,  and  not  to  a  surface  deposit  of  black  such  as  is  commonly 
found  in  the  mouths  of  smokers.  The  latter  is  a  characteristic 
jet  black  discoloration,  unmistakably  from  tobacco  smoke,  while 
the  former  is  less  intensely  black,  with  sometimes  a  greenish  tinge, 
— especially  where  it  has  been  long  in  contact  with  the  gum, — and 
its  source  is  not  so  apparent. 

Serumal  Calculus. 

Tliis  deposit  is  distinguishable  from  salivary  calculus  in  several 
particulars,  but  chiefly  in  its  initial  point  of  location  on  the  tooth. 
Salivary  calculus  finds  its  lodgment  on  that  portion  of  the  tooth 
which  is  batlied  in  saliva,  and  therefore  becomes  adherent  to  the- 
crown  o)-  neck  of  tlie  tootli,   llic   ]i;ir1    not  covered  by  the  giini. 


14 


PRINCIPLES   AA'D  PEACTICE  OF  FILLING  TEETH. 


It  mav  advance  and  force  the  gum  and  adjacent  tissues  back  so 
as  to  follow  the  root  to  the  apex,  as  in  Fig.  1;  and  yet  it  begins 
not  under  the  gum,  but  crownwise  of  it.  Serumal  calculus,  on 
the  contrary,  attaches  itself  to  the  root  of  the  tooth,  or  to  that 
portion  of  the  neck  which  is  covered  by  the  gum.  The  source  of 
this  deposit  is  therefore  different  from  salivary  calculus,  and,  as 
its  name  implies,  it  is  supposed  to  be  from  the  serum  of  the  blood. 
In  fact,  it  has  sometimes  on  this  account  been  termed  sanguinary 
calculus,  though  it  would  appear  that  there  are  certain  formations 
of  this  deposit  which  cannot  well  be  considered  as  coming  directly 
from  the  blood.  In  chronic  alveolar  abscess  we  often  find  upon 
the  apex  of  a  root  which  has  been  for  some  time  constantly  bathed 


Fig.  4. 


Fig  5. 


in  pus  the  characteristic  serumal  deposit.  But  it  at  least  may 
safely  be  stated  that  serumal  calculus  is  a  deposit  from  the  fluids 
which  surround  the  root  of  the  tooth,  while  salivary  calculus  is 
deposited  from  the  fluids  in  contact  with  the  crown. 

Another  point  of  distinction  between  the  two  is  found  in  the 
relative  bulk  of  the  deposit.  Salivary  calculus,  as  we  have  seen, 
may  assume  extensive  proportions,  while  serumal  calculus,  on 
account  of  its  environment,  is  restricted  in  growth,  and  is  usually 
found  in  the  form  of  small  nodules,  narrow  bands,  or  thin  scales 
(Figs.  4  and  5).  These  are  ordinarily  attached  quite  firmly  to 
the  surface  of  the  root,  and  require  considerable  force  to  dislodge 
them.  It  is  probable  that  the  irritation  produced  by  serumal 
calculus  under  the  gums  is  accountable  for  many  of  the  diseases 
to  be  found  in  the  surrounding  tissues,  and  which  frequently  lead 
to  loss  of  the  teeth,  it  being  impossible  to  conceive  of  gums  re- 
maining healthy  with  any  considerable  deposit  of  serumal  calculus 
under  them. 


DEPOSITS    OX    THE    TEETH.  15 

The  color  of  serumal  calculus  is  usually  darker  than  that  of 
salivary  calculus,  and  quite  commonly  has  a  greenish  tinge  run- 
ning through  it.  It  is  also  dense  in  structure,  and  is  probably 
formed  more  slowly  than  salivary  calculus.  It  may  be  found  in 
some  instances  deposited  in  a  thin  scale  along  the  side  of  the  root 
where  the  peridental  membrane  has  been  lost,  or  it  may  occur  as 
small  nodules,  particularly  at  the  apex  of  a  root,  as  the  result  of 
chronic  alveolar  abscess.  In  other  cases,  where  the  attachment  of 
the  ]3eridental  membrane  to  the  root  seems  perfect  from  the  apex 
to  near  the  alveolar  border,  but  where  the  free  margin  of  the  gum 
is  congested  and  puffed,  a  narrow  band  of  calculus  may  be  found 
encircling  the  neck  of  the  tooth  in  its  entire  circumference  just 
under  the  gum.  This  is  sometimes  so  near  the  margin  of  the  gum 
that  it  may  readily  be  seen  by  forcing  the  gum  back  with  a  pledget 
of  cotton.  In  any  pocket  formed  between  the  gum  and  the  root 
as  the  result  of  the  loss  of  that  portion  of  the  peridental  membrane, 
we  may  ordinarily  expect  to  find  more  or  less  of  a  deposit  of 
serumal  calculus,  and  we  need  not  hope  to  see  the  gum-tissue  over- 
lying this  become  healthy  so  long  as  the  deposit  is  allowed  to 

remain. 

Stains  on  the  Teeth. 

These  may  present  themselves  in  varying  degrees  of  extent  and 
intensity,  and  in  varying  shades  of  color.  The  one  claiming  most 
attention  from  the  profession  in  the  past  is  green  stain,  which 
seems  to  occur  with  the  greatest  frequency  on  upper  incisors  in 
young  patients.  It  may  also  be  found  in  certain  instances  coating 
the  entire  buccal  and  labial  surfaces  of  all  of  the  teeth  in  adults, 
though  this  is  comparatively  rare.  It  would  appear  strange  that 
so  much  prominence  had  been  given  green  stain  to  the  almost  com- 
plete ignoring  of  the  other  varieties.  In  point  of  frequency  the 
brownish  stains  are  more  prevalent,  and  they  are  found  occurring 
at  all  ages  and  upon  any  of  the  surfaces  of  the  teeth  not  subjected 
to  considerable  friction. 

All  of  the  stains  seem  to  form  witli  tlie  greatest  intensity  near 
tlie  gum-margin,  and  gradually  shade  away  toward  the  occlusal 
surface,  though  in  some  instances  tlicy  constitute  a  more  or  less 


16  PKIISrCIPLES   AND  PRACTICE   OF   FILLIjNTG   TEETH. 

well-defined  concentric  band  near  the  gingival  line,  following  the 
curvature  of  the  gum,  and  including  the  lingual  as  well  as  the 
labial  surfaces.  There  is  a  wide  variation  in  the  degree  of  tenacity 
with  which  these  stains  adhere  to  the  surfaces  of  the  teeth ;  in  some 
instances  the  slightest  friction  being  all  that  is  necessary  to  remove 
them  completely,  while  in  others  they  seem  almost  part  and  parcel 
of  the  enamel  itself.  The  green  stains  are  usually  more  adherent 
than  the  brown,  and  in  cases  of  great  intensity  of  stain  the  surface 
of  the  enamel  seems  disintegrated  and  roughened  after  its  removal. 
The  indications  in  every  instance  are  for  the  perfect  polishing 
away  of  all  such  stains  upon  the  teeth,  the  fact  of  their  unsightli- 
ness  being  an  all-sufficient  reason  for  such  a  procedure  outside  of 
the  somewhat  undetermined  point  as  to  their  possible  deleterious 
effect  wpon  the  enamel. 

The  origin  of  these  stains  seems  not  yet  definitely  settled. 
Various  writers  have  advanced  different  theories  upon  the  subject^ 
probably  the  most  noteworthy  of  which  is  that  of  Professor  W.  D. 
Miller  in  the  Dental  Cosmos,  April,  1894.  His  conclusions  seem 
to  lead  to  the  inference  that  the  different  stains  are  caused  by 
different  agencies,  and  that  no  one  theory  will  account  for  all 
cases.  In  the  light  of  the  diversity  of  opinion  expressed  by 
writers  upon  this  subject,  it  would  appear  unprofitable  to  consider 
it  in  detail  at  this  time. 

Another  variety  of  discoloration  upon  the  teeth  may  be  men- 
tioned as  being  distinct  from  the  green  and  brown  stains,  and  of  a 
character  entirely  peculiar  to  itself.  This  is  the  black  deposit 
caused  by  tobacco  smoke.  It  may  be  found  adherent  to  the  teeth 
of  smokers  much  the  same  as  the  other  stains,  except  that  it  is 
more  prevalent  on  the  lingual  surfaces,  and  it  has  more  appreciable 
bulk.  It  may  be  scraped  away  with  instruments,  leaving  the 
enamel  apparently  unaffected  under  it;  but  it  does  not  accumulate 
like  salivary  calculus,  so  as  to  impinge  upon  the  gum  or  cause  irri- 
tation to  the  surrounding  parts.  In  instances  of  the  long-con- 
tinued use  of  tobacco  the  structure  of  the  teeth  themselves  may 
become  so  stained  as  to  permanently  remain  so,  particularly  where 
the  enamel  is  gone  and  the  dentine  exposed  to  the  smoke. 


DEPOSITS    ON    THE    TEETH.  lY 

REMOVAL    OF   DEPOSITS. 

Removal  of  Salivary  Calculus. 

There  are  two  principal  plans  of  manipulative  procedure  for  the 
removal  of  salivary  calculus,  the  push-cut  method  and  the  draw- 
cut  method,  each  having  different  forms  of  instruments  adapted 
to  its  use.  Bv  the  push-cut  method  the  blade  of  the  scaler  is 
brought  to  bear  upon  the  calculus  at  the  point  nearest  the  occlusal 
surface  of  the  tooth,  and  the  mass  dislodged  by  forcing  the  scaler 
between  the  calculus  and  the  enamel  in  the  direction  of  the  root. 
By  the  draw-cut  method  the  scaler  is  placed  rootwise  of  the  deposit, 
and  force  applied  by  pulling  toward  the  occlusal  surface.  Each 
method  has  its  advocates  in  the  profession,  and  each  is  applicable 
to  certain  conditions,  the  best  practice  probably  being  to  use  them 
interchangeably,  as  circumstances  suggest.  The  limitations  of  the 
draw-cut  method  relate  to  the  fact  that  to  force  an  instrument  of 
sufficient  size  for  the  removal  of  salivary  calculus  far  enough  root- 
wise  to  seize  the  deposit  frequently  involves  considerable  impinge- 
ment on  the  gum,  mth  consequent  laceration ;  while  by  the  skillful 
use  of  the  push-cut  instrument  the  deposit  may  often  be  forced 
away  without  touching  the  gum  at  all.  On  the  other  hand,  the 
push-cut  method  invites  a  certain  danger  which  is  never  present 
with  the  draw-cut.  The  application  of  force  directly  toward  the 
gum  carries  with  it  the  constant  possibility  of  the  instrument 
slipping  and  wounding  the  gum,  while  a  slip  of  the  draw-cut  instru- 
ment is  comparatively  harmless.  The  element  of  apprehension  on 
the  part  of  the  patient  when  the  push-cut  is  being  used  is  some- 
times a  menace  which  invites  accidents  from  the  patient  flinching 
on  the  application  of  force,  thus  causing  the  instrument  to  glide 
into  the  gum.  To  avoid  accidents  of  this  nature,  and  to  carry 
assurance  to  the  mind  of  the  patient,  it  is  always  necessary  before 
applying  any  force  with  the  scaler  to  so  guard  the  hand  of  the 
operator  against  undue  movement  that  the  instrument,  in  case  it 
does  slip,  will  not  be  carried  into  the  gum.  This  can  be  done  by 
bracing  the  unused  fingers — the  ones  not  grasping  the  scaler — 
finiily  against  the  occlusal  surfaces  of  the  teeth  before  applying 

2 


18  PBIlSrOIPLES    AND    PBACTICE    OF    FILLING    TEETH. 

the  scaler  to  tlie  deposit.  By  this  means  a  perfect  control  may  be 
maintained  over  the  instrument,  and  a  sense  of  security  imparted 
to  the  patient  which  usually  results  in  a  reasonable  degree  of 
confidence  during  the  operation.  This  matter  of  creating  confi- 
dence on  the  part  of  the  patient  is  an  important  element  in  con- 
ducting a  successful  practice  in  all  lines  of  procedure,  and  the 
operator  should  study  the  manipulation  of  instruments  to  this  end. 
The  cardinal  principles  in  operating  should  be  precision  of 
methods,  firmness  of  control,  and  delicacy  of  execution.  Patients 
are  more  susceptible  to  impressions  made  upon  them  through 
manipulative  procedure  than  the  average  operator  would  seem  to 
conceive  of.  They  are  quick  to  recognize  superior  skill  in  an 
operator  by  reason  of  his  mastery  of  instruments  and  the  apparent 
intelligence  with  which  he  approaches  his  work,  and  there  are  few 
operations  in  dentistry  calling  for  a  more  diversified  order  of  skill 
than  the  successful  removal  of  calculus  from  the  teeth. 

The  cases  are  so  varied  in  their  nature,  both  as  regards  the 
extent  and  location  of  the  deposit  and  also  the  character  of  the- 
teeth  and  their  position  in  the  arch,  that  it  may  almost  be  said  that 
each  case  constitutes  a  law  unto  itself,  and  must  be  approached  in 
accordance  with  its  individual  requirements.  And  yet  it  would 
seem  desirable  to  formulate  so  far  as  possible  definite  rules  of 
procedure  in  this  as  in  all  other  operations  on  the  teeth,  though 
the  fact  must  constantly  be  borne  in  mind  that  in  any  formulation 
of  this  nature  the  element  of  personal  equation  must  necessarily 
enter  conspicuously  into  it  and  largely  influence  its  details.  ISTo 
two  men  need  be  expected  to  approach  this  work  in  precisely  the 
same  way,  though  each  should  at  least  study  out  some  systematic 
order  of  procedure  for  his  own  guidance,  so  as  to  accomplish  the 
result  in  an  orderly  sequence,  rather  than  by  haphazard  and  slip- 
shod methods.  Lack  of  system  in  the  performance  of  our  work 
has  been  one  of  our  chief  limitations  as  operators,  and  it  is  account- 
able for  a  grievous  waste  of  time  both  to  practitioner  and  patient. 

The  methods  here  suggested  are  not  applicable  to  all  cases,  nor 
will  they  probably  appeal  to  all  operators;  but  it  is  confidently 
hoped  that  they  may  at  least  prove  helpful  to  those  who  in  the- 


DEPOSITS    OX    THE    TEETH. 


19 


past  have  not  thought  it  necessary  to  employ  any  particular  method 
in  these  operations. 

Instruments  for  the  Removal  of  Calculus. 

The  instruments  here  illustrated  are  largely  adaptations  from 
or  modifications  of  the  forms  long  since  introduced  to  the  profes- 
sion by  various  operators.  Tig.  6  is  a  somewhat  sickle-shaped 
contra-angle  instrument,  having  three  sides  for  cutting.  It  may 
therefore  be  used  interchangeably  as  a  push-cut  or  draw-cut  instru- 
ment, though  the  shai'pest  or  most  acute  edge  being  along  the 
extremity  of  the  instrument  gives  it  greater  efficiency  as  a  push- 


FiG.  6.  Fig. 


Fig.  8.  Fio.  D.  Fig.  10.  Fig.  11.  Fig.  12.  Fig.  1-3.  Fig.  14.  Fig.  15. 


cut  tlian  as  a  draw-cut.  Its  uses  will  be  indicated  hereafter. 
Fig.  7  is  an  ordinary  direct  push-cut  scaler,  with  the  curvature 
somewhat  nearer  the  cutting-edge  than  usual;  while  Fig.  8  is  a 
long,  slender,  delicate  instrument  for  reaching  places  inaccessible 
to  Fig.  7.  Figs.  9,  10,  and  11,  designed  by  Dr.  A.  G.  Johnson, 
are  hooked  instruments  of  varying  forms  for  draw-cut  work  along 
the  roots  of  teeth  in  pockets  under  the  gum.  The  distinguishing 
feature  between  these  and  the  instruments  generally  suggested  for 
this  purpose  relates  to  the  reverse  side  of  the  scaler.  Ordinarily 
the  back  of  the  scaler — the  side  coming  in  contact  with  the  gum 
in  passing  between  it  and  the  root — is  left  with  sharp  angles  and 
corners,  which  inflict  unnecessary  di.scomfort  on  the  patient  by 
lacerating  the  gum.     In  the  ones  liero  .shown  these  angles  are 


20  pkijN'Ciples  and  practice  of  filling  teeth. 

rounded  off,  so  as  to  leave  a  smooth  back  to  tlie  instrument,  which 
may  be  insinuated  under  the  gum  and  along  the  root  without 
serious  disturbance  to  the  patient.  Fig.  12  is  merely  a  short- 
bladed  hoe  excavator,  while  Fig.  13  is  a  delicate  hatchet  excavator, 
the  uses  for  which  will  be  considered  later.  Fig.  14  is  a  curved 
wide  push-cut  scaler  for  passing  over  the  surfaces  of  teeth  where 
the  bulk  of  the  deposit  has  already  been  removed,  and  scraping  off 
any  small  particles  that  may  have  been  left.  Fig.  15  is  a  long- 
reach  push-cut  scaler  for  approaching  localities  in  special  cases 
inaccessible  to  the  ordinary  instruments. 

Technique  of  the  Operation. 

In  the  examination  for  calculus  on  the  teeth  probably  nine  out 
of  ten  operators  will  instinctively  place  the  mouth-mirror  between 
the  tip  of  the  tongue  and  the  lower  incisors,  and  reflect  the  light 
upon  the  lingual  surfaces  of  these  teeth.  It  is  therefore  natural 
that  the  removal  of  the  deposits  should  begin  at  this  point,  and 
there  is  also  another  minor  reason  why  it  is  well  to  start  where 
there  is  considerable  material  to  be  removed.  It  makes  an  instan- 
taneous impression  on  the  mind  of  the  patient  as  to  the  extent  of 
the  deposit  present,  and  arouses  an  interest  in  the  work  which 
nothing  else  will.  It  is  seldom  that  a  patient  realizes  just  how 
much  calculus  there  is  upon  the  teeth,  due  to  its  gradual  formation 
and  the  fact  that  the  tongue  becomes  accustomed  to  its  presence. 
But  if,  on  the  first  introduction  of  the  scaler,  several  large  pieces 
are  flaked  off  and  allowed  to  fall  into  the  floor  of  the  mouth,  the 
patient  is  startled  into  a  realization  of  what  has  been  going  on,  and 
is  impressed  with  the  importance  of  proper  attention  to  the  matter 
in  the  future.  The  same  impression  never  seems  possible  later  on 
in  the  operation  if  the  large  masses  are  left  till  the  last. 

For  the  removal  of  salivary  calculus  from  the  lingual  surfaces 
of  the  lower  incisors  in  ordinary  cases  the  scaler  illustrated  in 
Fig.  6  is  admirably  adapted.  (It  need  not  here  be  urged  that  all 
scalers  should  be  keenly  sharp  in  whatever  location  they  are  used.) 
With  the  mouth-mirror  in  the  left  hand,  and  held  in  such  a  posi- 
tion that  the  tongue  is  kept  well  away  from  the  lower  incisors  and 


DEPOSITS    0:S    THE    TEETH.  21 

the  light  thrown  upon  the  deposit,  the  first  movement  of  the 
operating  hand  should  be  to  firmly  brace  the  end  of  the  third 
finger  against  the  occlusal  surfaces  of  the  adjacent  teeth  in  such  a 
manner  that  the  patient  must  at  once  realize  that  the  operator  has 
complete  control  of  the  instrument  against  slipping.  This  ac- 
complished, rapid  work  is  possible.  A  push-cut  should  be  used 
along  the  disto-lingual  surface  of  the  right  lower  lateral,  and  the 
deposit  dislodged.  Immediately  this  is  done  the  point  of  the 
instrument  should  be  turned  rootwise  of  the  deposit  on  the  mesio- 
lingual  surface  of  the  same  tooth,  and  a  draAv-cut  given  to  flake  it 
off  along  that  surface.  Thus  with  two  movements,  one  downward 
and  the  other  upward,  the  large  bulk  of  calculus  from  that  tooth 
has  been  dislodged  in  the  most  expeditious  manner.  The  same 
plan  should  be  followed  successively  with  the  other  teeth  in  line 
as  far  as  the  left  cuspid,  when  the  sickle-shaped  scaler  should  be 
exchanged  for  Fig.  14.  With  this  the  entire  lingual  surfaces  of 
these  teeth  should  be  scraped  to  remove  any  small  particles  of 
deposit  which  may  have  been  left  by  the  other  scaler,  and,  follow- 
ing this,  attention  should  be  given  to  the  lingual  surfaces  of  the 
left  lower  bicuspids  and  molars.  Beginning  with  the  mesio- 
lingual  aspect  of  the  first  bicuspid,  these  surfaces  should  be  fol- 
lowed in  regular  order  to  the  distal  surface  of  the  left  lower  third 
molar,  the  instruments  usually  best  adapted  for  this  work  being 
either  the  hoe  or  hatchet  forms,  Tigs.  12  and  13.  The  lingual 
surfaces  of  all  of  the  lower  teeth  to  the  left  of  the  right  cuspid  have 
now  been  covered.  To  reach  the  lingual  surfaces  of  the  right 
cuspid  and  the  teeth  posterior  to  it  the  operator  should  step  slightly 
forward  and  face  his  patient,  so  as  to  look  along  these  teeth.  Then, 
with  the  hatchet  instrument  held  in  the  palm  and  the  thumb 
braced  against  the  teeth,  the  deposit  may  be  lifted  from  the  necks 
very  expeditiously. 

After  the  lingual  surfaces  are  attended  to  the  buccal  and  labial 
surfaces  may  ordinarily  be  reached  with  the  hatchet  instrument, 
using  the  pen  grasp  for  the  right  side  of  the  mouth  as  far  forward 
as  the  cuspid,  and  then  changing  to  the  palm  grasp  for  all  the 
teeth  to  tlie  left  of  that.     Those  surfaces  should  be  followed  sue- 


22  PRINCIPLES    AND    PEACTICE    OF    PILLING    TEETH. 

cessivelj  from  one  third  molar  to  the  other.  As  the  deposit  is 
being  lifted  from  the  labial  aspect  of  the  lower  incisors,  care 
should  be  taken  that  the  pieces  of  calculus  do  not  fly  into  the 
operator's  eyes.  The  force  is  necessarily  exerted  directly  toward 
the  operator,  and  the  particles  sometimes  snap  off  with  consider- 
able momentum,  so  that  accidents  of  this  nature  are  not  un- 
common. 

AVhen  large  masses  of  calculus  are  found  on  any  of  these  sur- 
faces, it  may  be  removed  with  the  push-cut  instruments.  Figs.  7 
or  14.  In  cases  of  great  recession  of  the  gum  and  extensive 
deposits  along  the  exposed  portion  of  the  roots,  particularly  if  the 
teeth  lean  in  toward  the  tongue,  so  that  they  stand  obliquely  in 
the  arch  and  are  very  long,  the  lingual  surfaces  can  only  be 
reached  to  good  advantage  with  an  instrument  like  Fig.  15.  In 
using  this  on  the  lower  incisors  or  right  cuspid,  bicuspid,  or  molars 
it  will  be  found  better  to  pass  to  the  left  side  of  the  patient  and 
throw  the  light  down  into  this  secluded  locality  with  the  mouth- 
mirror  in  the  left  hand.  The  right  hand,  graping  the  scaler,  may 
pass  around  the  patient's  head  to  the  right  angle  of  the  mouth,  so 
that  the  end  of  the  third  finger  rests  on  the  occlusal  surfaces  of  the 
teeth  in  the  region  of  the  right  lower  cuspid  or  first  bicuspid. 
Braced  in  this  way,  efl^ective  push-cutting  may  be  done  without 
impingement  on  the  gum. 

When  the  deposits  have  been  thoroughly  removed  from  the 
buccal,  labial,  and  lingual  surfaces  there  remain  only  the  proxi- 
mal surfaces  to  claim  attention.  For  this  work  where  there  has 
been  a  recession  of  the  gums,  and  the  deposit  is  accordingly  of  a 
salivary  formation,  the  push-cut  method  of  removal  is  by  far  the 
more  effective.  The  chair  should  be  raised  so  as  to  bring  the 
patient's  lower  teeth  well  opposite  the  operator,  and  a  direct  push- 
cut  exerted  from  labial  or  buccal  to  lingual  across  the  proximal 
su.rfaces.  For  this  work  the  scaler  Fig.  7  is  mostly  serviceable, 
though  in  some  cases  Fig.  8,  having  a  longer  reach  and  a  more 
delicate  form,  is  applicable.  There  are  certain  instances  where 
this  method  of  push-cutting  from  labial  to  lingual  on  the  lower 
incisors  is  indicated  at  the  very  outset  of  the  operation,  before  any 


DEPOSITS    ON    THE    TEETH.  23 

attempt  is  made  to  use  the  scaler  Fig.  6.  This  is  where  there  has 
been  much  recession  of  the  gums  and  the  interproximal  spaces  are 
vn.de  and  filled  with  calculus,  and  the  lingual  aspect  of  the  deposit 
presents  a  solid  phalanx  of  incrustation,  with  only  the  merest  line 
to  show  the  demarkation  between  the  different  teeth.  If  a  case 
of  this  kind  is  approached  from  the  labial  aspect  and  the  push-cut 
scaler  Fig.  7  is  forced  between  the  teeth  along  the  proximal  sur- 
faces toward  the  lingual,  the  large  masses  of  calculus  may  be. 
tumbled  off  into  the  mouth  with  astonishing  ease  and  rapidity. 

The  operator  should  study  the  various  means  of  attacking  these 
■deposits,  to  the  end  that  he  may  approach  the  work  in  the  dif- 
ferent phases  of  the  deposit  and  be  able  to  meet  each  case  in  the 
most  expeditious  manner. 

In  removing  salivary  calculus  from  the  upper  teeth  the  operator 
may  start  at  the  buccal  surface  of  either  third  molar.  The  work 
may  be  done  ^vith  push-cut  scalers  if  the  deposit  is  bulky,  or  with 
the  hatchet  and  hoe  forms  if  it  consists  only  of  a  narrow  ring  near 
the  gum.  For  the  proximal  surfaces  of  these  teeth  the  hatchet 
form  seems  best  adapted,  there  being  less  facility  for  employing 
the  ordinary  push-cut  instruments  than  with  the  lower  teeth.  It 
is  seldom  that  salivary  calculus  is  found  on  the  lingual  surfaces  of 
the  upper  teeth,  but  whenever  it  does  occur  it  can  best  be  removed 
with  the  hoe  form.  Fig.  12. 

Removal  of  Serumal  Calculus. 

This  operation  is  one  really  requiring  the  utmost  delicacy  of 
touch  and  the  highest  degree  of  digital  perception.  All  of  the 
work  is  done  under  cover  of  the  gum,  where  the  operator  cannot 
see,  and  consequently  the  sense  of  feeling  is  the  only  guide.  This 
sense  must  be  highly  developed  if  the  operator  expects  to  attain 
anything  like  success  in  this  work.  He  must  be  able  to  distinguish 
accurately  by  the  impressions  conveyed  to  him  through  contact  of 
the  instrument  with  the  root  of  the  tooth  whether  he  is  touching 
calcnlus  or  cementnm;  and  he  must  do  this  not  by  reason  of  the 
bulk  of  the  deposit,  but  from  the  nature  of  its  density.  There  is 
a  decided  difference  in  the  character  of  the  two  substances,  and 


24  PKINCIPLES    AND    PEACTICE    OF    PILLING-    TEETH. 

the  practiced  operator  can  make  a  sharp  distinction  between  them. 
The  necessity  for  this  lies  in  the  fact  that  in  many  instances  the 
formation  is  limited  to  the  thinnest  possible  scale  along  the 
side  of  the  root,  sometimes  resting  in  a  concavity,  so  that  there 
is  no  appreciable  elevation  of  the  deposit  over  the  surface  of  the 
root.  In  such  cases  the  instrument  must  be  gently  raked  over 
the  surface,  and  the  line  of  demarkation  detected  between  the 
deposit  and  the  cementum.  This  may  be  done  by  carefully  noting 
the  difference  in  the  effect  upon  the  blade  of  the  instrument  when 
encountering  the  two  materials,  cementum  and  calculus.  In  pass- 
ing over  cementum  a  sharp  instrument  will  readily  peel  up  the 
tissue  and  scrape  it  off,  much  as  one  may  scrape  a  bit  of  bone.  It 
has  a  dead,  comparatively  soft  consistence,  so  that  the  scaler 
"bites"  into  it  readily.  With  serumal  calculus  the  case  is  dif- 
ferent. The  scaler  encounters  a  hard,  flint-like  substance,  "svhich 
gives  a  decided  resistance  to  the  instr^^ment,  and  which  cannot  be 
scraped  to  lessen  its  bulk.  It  must  be  dislodged  en  masse  or  not 
at  all,  By  cautiously  feeling  along  the  root  the  expert  operator 
is  thus  enabled  to  detect  the  slightest  flake  of  calculus  and  to 
remove  it. 

The  instruments  best  adapted  for  this  delicate  kind  of  work  are 
the  hooked  forms,  Figs.  9,  10,  and  11.  They  may  be  insinuated 
up  under  the  gum  into  a  pocket  alongside  the  root,  and  thus  scrape 
it  free  from  deposits  with  a  draw-cut.  The  straight  form,  Fig.  9, 
will  be  found  serviceable  for  most  of  the  work,  though  occasional 
cases,  on  posterior  teeth  call  for  the  curved  forms,  10  and  11. 
Fig.  10  may  be  used  on  the  distal  surfaces  of  molar  and  bicuspid 
roots,  while  Fig.  11  will  best  reach  the  mesial  surfaces  of  such 
teeth.  The  greatest  patience  and  perseverance  are  necessary  for 
the  thorough  removal  of  this  thin  scale-like  deposit,  but  no  opera- 
tor does  his  full  duty  to  his  patient  when  he  allows  it  to  remain. 

There  is  another  variety  of  deposit  coming  under  the  head  of 
serumal  which  is  distinct  from  the  scale-like  form,  and  is  fre- 
quently met  in  cases  where  there  is  no  appreciable  pocl^et.  This 
is  a  narrow  ring  encircling  the  root  just  under  the  free  margin  of 
the  gum,  dark  in  color,  dense  in  structure,  and  well  defined  in 


DEPOSITS    ON    THE    TEETII. 


9r> 


outline.  The  only  indication  of  its  presence  is  a  slightly  puffed 
and,  congested  condition  of  the  gum  lying  over  it,  and  in  some 
instances  even  this  is  not  very  apparent  until  the  deposit  assumes 
appreciable  size.  It  cannot  be  seen  by  the  operator  without  press- 
ing the  gum  back  from  the  neck  of  the  tooth,  but  it  may  be  felt 
with  a  fine  explorer.  It  is  often  present  on  the  proximal  sur- 
faces without  forming  on  the  others,  and  it  seems  to  work  its 
greatest  injury  between  the  teeth.  If  allowed  to  go  unchecked 
it  results  in  a  detachment  of  the  gum  from  the  root  in  the  inter- 
proximal space,  and  a  general  impairment  and  puffing  of  the 
gum-festoons. 

The  removal  of  this  band  of  calculus  is  usually  best  accom- 
plished on  the  lower  jaw  by  delicate  push-cut  scalers,  and  the  work 
is  greatly  facilitated  if  the  operator  will  pack  the  interproximal 
spaces  in  advance  with  small  pellets  of  cotton  to  force  back  the 
gum,  so  as  to  expose  the  deposit.  The  cotton  requires  to  be  in 
only  a  few  minutes,  and  on  its  removal  the  scaler  must  be  con- 
veniently at  hand  in  order  to  accomplish  the  work  before  the  gum 
creeps  back  over  the  deposit.  A  ready  method  of  procedure  is  to 
force  cotton  into  two  or  three  spaces  and  keep  that  number  in 
advance  of  the  operation,  so  that  by  the  time  each  space  is  reached 
the  gum  will  be  Avell  out  of  the  way.  In  this  manner  the  calculus 
can  ordinarily  be  seen  distinctly,  and  removed  more  expeditiously 
than  if  it  were  all  done  solely  by  the  sense  of  touch.  For  the 
upper  teeth  the  delicate  hatchet  excavator  will  usually  be  indicated 
in  place  of  the  push-cut  instruments,  and  in  some  localities,  par- 
ticularly along  the  lingual  surfaces,  the  hoe  form  will  be  most 
effective. 

The  surfaces  of  all  roots  where  serumal  calculus  has  found  at- 
tachment should  be  very  carefully  scraped  and  left  smooth,  so  that 
the  gum  may  resume  its  normal  position  and  tonicity.  If  small 
particles  of  the  deposit  are  overlooked  and  allowed  to  remain 
they  not  only  irritate  the  gum,  but  they  invite  the  rede- 
position  of  fresh  calculus  so  that  the  relief  is  only  temporary. 
The  gum  need  not  be  expected  to  become  healthy  where  any 
appreciable  particles  of  the  deposit  are  left,  and  in  a  week  or  two 


26  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

after  the  operation  for  removal  it  is  frequently  possible  to  locate 
the  precise  points  at  which  flakes  of  calculus  have  been  overlooked, 
on  account  of  the  appearance  of  the  gums  at  these  places.  If  a 
purplish  or  congested  condition  of  the  gum  persists  at  certain 
points,  it  may  be  taken  as  an  almost  infallible  indication  that  a  bit 
of  serumal  calculus  is  lying  under  it.  These  facts  are  eloquent 
object-lessons  as  to  the  necessity  for  constant  vigilance  in  keeping 
the  teeth  free  from  deposits. 

Removal  of  Stains  from  the  Teeth. 

After  salivary  calculus  has  been  removed  with  instruments,  it 
will  usually  be  found  that  the  surfaces  formerly  covered  by  the 
deposit  are  left  somewhat  roughened  and  in  need  of  polishing  to 

Fig.  16. 


prevent  a  ready  attachment  of  fresh  calculus,  while  the  surfaces 
extending  from  the  point  of  deposit  are  ordinarily  more  or  less 
stained  and  unsightly.  To  complete  the  operation  as  it  should  be, 
and  also  to  remove  stains  from  the  teeth  where  there  has  been  no 
salivary  calculus,  it  is  necessary  to  so  polish  the  surfaces  of  the 
teeth  by  friction  that  the  enamel  will  assume  a  white  and  glisten- 
ing appearance. 

This  is  best  accomplished  by  rotary  appliances  in  the  engine  in 
the  form  of  brushes,  rubber  cones,  or  moose-hide  points  carrying 
pulverized  pumice.  Probably  the  most  effective  method  in  "ordi- 
nary cases  is  to  use  the  small  polishing  brushes  made  for  the  pur- 
pose, Fig.  16,  though  there  are  occasionally  places  where  the  cones 
or  points  may  reach  to  better  advantage.  The  brushes  should 
invariably  be  of  the  stifPer  variety,  on  account  of  the  tendency  to 
soften  from  the  moisture  after  a  few  revolutions  on  the  tooth.  If 
the  brush  becomes  soft  it  is  useless.  *    . 


DEPOSITS    ON    THE    TEETH.  27 

The  maimer  of  using  the  brush  is  to  place  its  end  against  the 
surface  to  be  polished,  and  as  the  engine  revolves  to  cause  gentle 
pressure.  The  degree  of  pressure  will  determine  the  area  of 
enamel  to  be  covered  by  the  brush  from  the  spreading  of  the 
bristles,  Fig.  16,  and  in  this  vray  the  brush  may  be  made  to  con- 
form accurately  to  the  curvature  of  the  gum,  and  thus  polish  the 
enamel  close  to  the  gingival  line  without  lacerating  the  gum  or 
irritating  it.  All  of  the  exposed  surfaces  of  the  teeth  should  be 
included  in  the  polishing  till  the  last  vestige  of  stain  is  removed, 
except  in  those  cases  where  the  tooth-tissue  itself  is  discolored  from 
tobacco  or  other  causes.  This,  of  course,  cannot  be  polished  off, 
though  even  a  tooth  in  this  condition  should  be  made  as  smooth  on 
the  surface  as  possible  by  friction  of  the  brush. 

In  moistening  the  pumice  for  the  removal  of  stains  it  is  well  to 
use  some  other  liquid  than  water.  Miller  found  that  the  peroxide 
of  hydrogen  had  a  solvent  effect  on  green  stain,  and  it  is  an 
admirable  cleansing  agent  in  a  general  way.  While  the  main 
reliance  in  the  removal  of  these  stains  should  be  the  mechanical 
friction  of  the  pumice,  yet  there  would  seem  to  be  no  objection  to 
employing  adjuncts  in  the  form  of  liquids  having  an  antiseptic  or 
disinfectant,  as  well  as  a  solvent,  action  such  as  this.  In  cases  of 
highly  congested  gums,  where  the  slightest  contact  of  the  brush 
causes  profuse  bleeding,  it  may  be  well  to  use  with  the  pumice 
some  one  of  the  astringent  mouth-washes  on  the  market  whose 
formulae  are  published  and  known  to  the  operator.  It  is  also  a 
relief  to  the  patient  after  a  sitting  for  the  removal  of  calculus, 
where  there  has  necessarily  been  considerable  wounding  of  the 
gums,  to  add  some  of  this  wash  to  the  water  used  for  rinsing  the 
mouth.  In  every  case  where  pumice  has  l)een  employed  the  teeth 
and  gums  should  be  thoroughly  syringed  with  tepid  solutions  to 
remove  as  perfectly  as  possible  all  traces  of  the  pumice,  which  is 
insoluble  in  the  mouth,  and  which  should  not  be  left  lodging  in  any 
quantity  around  the  gum-margins. 

Two  items  bearing  on  the  hygiene  of  this  operation  must  he 
mentioned;  not  because  they  are  not  patent  to  every  conscientious 
flufl  observant  operator,  but  l)ecause  there  seems  to  be  much  laxity 


28  PRINCIPLES    AND    PRACTICE    OP    FILLING    TEETH. 

in  these  minor  details  on  the  part  of  some  in  the  profession.  No- 
polishing  brush  should  ever  be  used  under  any  possible  circum- 
stance in  more  than  one  mouth.  They  are  made  in  such  quanti- 
ties by  the  manufacturers,  and  are  so  inexpensive,  that  there  is  no- 
manner  of  excuse  for  so  gross  a  violation  of  personal  and  profes- 
sional refinement.  Outside  of  the  question  of  conveying  infec- 
tion, the  idea  must  be  sufiiciently  revolting  to  make  more  than  a 
mere  mention  of  it  unnecessary.  The  moment  a  set  of  teeth  is 
polished  the  brush  used  should  at  once  be  discarded,  and  a  fresh 
one  placed  in  the  mandrel,  which  itself  should  be  cleaned  each 
time  it  is  used.  The  other  item  relates  to  mixing  the  pumice. 
The  same  mix  should  not  be  made  to  do  service  for  more  than  one 
individual.  A  convenient  quantity  should  be  prepared  in  a  small 
glass  or  porcelain  dish  for  each  patient,  and  the  dish  thoroughly 
cleaned  after  using.  These  simple  precautions  are  not  only  de- 
manded on  the  basis  of  professional  integrity,  but  they  are  really 
remunerative  in  the  way  of  inviting  patronage  of  the  most  desir- 
able kind.  Patients  are  more  observant  of  these  matters  than  is 
generally  supposed,  and  they  are  usually  appreciative  of  every 
effort  which  insures  to  them  cleanliness  and  protection. 

Instructions  to  Patients  as  to  the  Care  of  the  Teeth. 

The  dentist  has  done  much  less  than  his  whole  duty  if  he  con- 
tents himself  with  the  mere  performance  of  the  operation  of  clean- 
ing the  teethj  and  fails  to  so  instruct  his  patient  that  they  may 
thereafter  be  kept  clean.  Comparatively  few  individuals  really 
know  how  best  to  care  for  the  teeth,  and  it  should  be  the  office  of 
the  dentist  to  so  educate  those  coming  under  his  charge  that  the 
result  will  be  a  more  general  enlightenment  on  this  important  sub- 
ject. An  opportune  moment  for  making  an  appreciable  impres- 
sion is  just  at  the  conclusion  of  a  sitting  for  the  removal  of  calculus 
and  stain,  when  the  patient's  mind  will  most  likely  be  in  a  recep- 
tive mood  on  the  subject. 

The  technique  of  brushing  the  teeth  should  be  explained  so 
that  the  patient  may  learn  how  to  reach  all  of  the  surfaces  with 
the  brush,  and  to  impart  the  requisite  friction  to  the  gums  and 


DEPOSITS    ON"    THE    TEETH.  29 

teeth  without  doing  injury.  The  ill-advised  cross-brushing  of 
teeth  ^vith  grittv  powders  has  undoubtedly  done  much  harm  in 
wearing  the  enamel  and  in  forcing  the  gum  away  from  the  necks 
of  the  teeth,  so  as  to  admit  of  a  groove  being  cut  by  the  brush 
just  rootwise  of  the  enamel.  Cross-brushing  is  not  entirely  un- 
avoidable in  a  thorough  cleansing  of  the  teeth,  nor  is  it  at  all  injuri- 
ous if  used  with  judgment,  but  the  patient  should  be  taught  the 
danger  of  an  indiscriminate  sawing  against  the  necks  of  the  teeth 
^vitli  a  stiff  brush  loaded  with  a  gritty  powder  or  paste.  The  general 
plan  of  brushing  the  teeth  should  be  to  produce  a  sort  of  rotary 
movement  with  the  brush,  so  as  to  bring  the  bristles  against  the 
lower  gums  and  teeth  on  the  upward  motion  and  against  the  upper 
ones  on  the  downward  motion.  This  cannot  be  done  with  any- 
thing like  precision  on  all  of  the  teeth,  but  it  should  be  the  general 
aim  with  the  idea  ever  in  mind  that  the  gums  require  friction  as 
well  as  the  teeth,  and  that  they  must  be  brushed  against  the  necks 
of  the  teeth  instead  of  away  from  them.  In  cases  where  the 
patient  complains  that  the  gums  are  too  sensitive  to  admit  of  proper 
brushing  of  the  teeth,  they  should  be  subjected  to  a  thorough 
system  of  massage  with  the  fingers  three  or  four  times  a  day  till 
they  become  sufficiently  hard  to  comiortably  tolerate  any  ordinary 
brushing. 

As  to  the  frequency  with  which  teeth  must  be  brushed  by  the 
patient  to  keep  them  well  cleaned,  no  definite  rule  can  be  given 
on  account  of  the  variation  in  the  different  mouths.  In  one  indi- 
vidual the  teeth  may  be  kept  in  admirable  condition  Avith  one-half 
the  care  that  would  be  necessary  for  another,  and  even  in  the  same 
individual  there  is  considerable  variation  at  different  periods  in  the 
tendency  to  the  accumulation  of  deposits.  Patients  must  there- 
fore be  requested  to  study  the  matter  on  their  own  behalf  till  they 
learn  with  some  degree  of  accuracy  just  how  much  care  is  neces- 
sary to  keep  the  teeth  bright  and  clean. 

The  use  of  floss  for  passing  between  the  teeth  and  removing 
any  particles  which  may  be  found  lodging  where  the  brush  will 
not  reach  is  an  admirable  practice,  provided  the  patient  will  use  it 
judiciously  and  without  working  injury  to  the  gum.     The  great 


30  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

danger,  as  used  by  most  individuals,  lies  in  the  fact  that  in  passing- 
it  between  the  teeth  it  is  inclined  to  snap  as  it  passes  the  contact 
j)oints  and  come  down  forcibly  upon  the  festoon  of  gum.  This 
may  in  time  injure  the  gum  and  force  it  back  in  the  interproxi- 
mal space,  leaving  the  space  imperfectly  filled  with  tissue.  When- 
ever floss  is  used  it  should  be  most  carefully  guarded  as  it  is  pass- 
ing the  contact  points  and  prevented  from  impinging  on  the  gum, 
and  unless  the  patient  can  gain  control  of  it  in  this  way  it  had 
better  not  be  used. 

One  feature  in  the  care  of  the  teeth  by  the  patient  must  not  be 
overlooked.  This  relates  to  the  use  of  toothpicks,  which,  if 
properly  employed  and  of  suitable  form,  may  be  used  to  advantage 
for  the  dislodgment  of  certain  kinds  of  food-material  from  between 
the  teeth,  but  which  if  used  as  they  too  commonly  are  may  result 
in  great  injury  to  the  gums.  The  large  blunt  wooden  toothpicks 
so  extensively  provided  for  the  patrons  of  public  eating-houses  are 
especially  calculated  to  work  irreparable  injury  if  persisted  in. 
Outside  of  the  rough  nature  of  the  wood  and  the  sharp  corners  and 
blunt  ends,  all  of  which  tend  to  irritate  the  gums,  the  very  bulk 
of  the  pick  is  such  as  to  finally  force  all  of  the  gum  out  of  the 
interproximal  space  and  furnish  a  receptacle  between  the  teeth 
for  the  constant  collection  of  food.  Dentists  should  invariably 
discourage  the  use  of  such  destructive  agents  as  these.  Whenever 
a  toothpick  is  indicated  at  all,  it  should  be  of  the  very  thinnest, 
smoothest,  and  most  flexible  nature.  Probably  the  best  toothpick 
is  the  quill,  which  can  be  scraped  with  a  knife  to  any  degree  of 
fineness  and  pliability.  The  constant  habit  of  picking  the  teeth, 
as  a  habit,  should  be  discouraged,  and  the  custom  limited  to  the 
mere  removal  of  particles  of  food  which  may  find  lodgment 
between  the  teeth. 


% 


DENTAL    CARIES.  31 

CHAPTEK   11. 

DENTAL  CARIES. 

It  is  scarcely  within  the  province  of  this  work  to  enter  minutely 
into  the  etiology  of  dental  caries,  and  yet  a  few  observations  bear- 
ing on  the  subject  from  an  operative  point  of  view  would  seem  to 
be  eminently  in  order.  Dental  caries  has  been  accounted  one  of 
the  most  prevalent  of  all  human  diseases,  and  one  of  the  most  per- 
sistent through  life,  in  view  of  which  it  would  appear  on  the  face 
of  it  a  very  discouraging  task  to  attempt  to  combat  this  affection. 
In  fact,  there  are  many  men  in  the  profession  who  apparently  give 
themselves  over  very  easily  to  this  idea,  and  consign  the  natural 
teeth  to  the  grasp  of  the  forceps  with  a  resignation  which  borders 
closely  on  an  assumption  of  the  inevitable.  This  ready  yielding 
on  their  part  has  its  influence  on  the  patient,  and  an  unfortunate 
impression  is  thus  allowed  to  go  out  to  the  effect  that  in  many  cases 
it  is  quite  impossible  to  save  the  teeth,  and  therefore  waste  energy 
to  make  the  attempt.  This  teaching  is  wrong  in  the  highest 
degree,  and  the  profession  has  much  to  answer  for  if  it  fails  to 
inform  itself  in  the  most  intimate  manner  on  the  true  relation  of 
this  disease  to  the  human  economy,  and  on  the  best  means  of 
securing  its  control. 

.  A  close  study  of  the  manifestations  of  dental  caries  will  reveal 
the  fact  that  while  it  may  be  considered  a  very  persistent  disease^ 
it  is  seldom  the  case  that  it  is  continuously  so  either  in  relation  to 
its  initial  appearance  or  the  degree  of  its  severity.  Some  of  the 
most  discouraging  cases  that  come  under  the  attention  of  the 
practitioner  will  be  found,  if  carefully  studied,  to  experience 
periods  of  immunity  from  attack,  during  which  the  process  of  decay 
seems  for  the  time  suspended.  In  fact,  it  is  the  exception,  rather 
than  the  rule,  for  teeth  to  go  progressively  to  destruction  from 
caries  one  after  the  other  till  every  tooth  is  lost  without  intervals 
of  practical  cessation  of  activity  on  the  part  of  the  micro-organisms 
which  bring  about  decay,  even  where  no  attempt  is  made  to  combat 


32  PEINCIPLES    AND    PRACTICE    OF    PILLING    TEETH. 

the  disease.  Cases  are  frequently  noted  where  a  number  of  teeth 
in  a  mouth  have  been  lost  through  caries  while  the  remaining  teeth 
present  themselves  years  afterward  practically  free  from  caries, 
the  disease  seemingly  becoming  limited  with  the  loss  of  the  teeth 
•that  are  missing.  It  might  be  thought  in  such  cases  that  there 
was  something  in  the  structure  of  the  remaining  teeth  which  ac- 
counted for  their  escape  were  it  not  for  the  fact  that  these  same 
teeth  may  at  a  subsequent  period,  without  any  appreciable  provoca- 
tion, take  on  an  active  attack  of  caries  and  require  the  closest 
attention  to  save  them. 

In  a  broad  view  of  the  whole  question  of  the  susceptibility  to  or 
immunity  from  caries,  it  seems  to  resolve  itself  down  to  the  fact 
that  in  some  mouths  the  conditions  are  such  that  the  micro-organ- 
ism of  caries  cannot  work  effectively  upon  the  teeth,  while  in 
others  they  are  favorable  to  its  most  active  influence,  and  that  in 
the  same  mouth  there  are  periods  when  the  conditions  favor  the 
work  of  the  micro-organism  and  others  when  they  interfere  with 
its  action.  Just  what  these  conditions  are  the  profession  at  present 
do  not  seem  to  be  able  to  determine,  but  the  recent  investigations 
of  Dr.  J.  Leon  Williams  would  appear  to  promise  an  encouraging 
step  toward  the  solution  of  the  problem.  Professor  W.  D.  Miller 
had  demonstrated  some  years  ago  that  caries  was  brought  about  by 
the  action  of  an  acid  produced  as  the  result  of  micro-organic  growth 
in  the  mouth,  and  Dr.  G.  Y.  Black  called  attention  to  the  fact  that 
this  acid  must  be  formed  and  allowed  to  act  immediately  at  the 
point  where  the  decay  was  to  begin.  (In  fact,  Robertson,  in  1828, 
indicated  that  the  carious  process  was  the  result  of  some  influence 
acting  directly  on  the  enamel  at  certain  points  where  the  cavities 
were  to  occur,  his  idea  being  that  this  influence  was  due  to  "decom- 
position.") It  was  therefore  seen  that  the  old  and  somewhat  preva- 
lent idea  that  the  reaction  of  the  saliva  had  something  to  do  with 
the  progress  of  caries  must  be  abandoned,  so  far,  at  least,  as  any 
direct  action  on  the  tooth-tissue  was  concerned.  It  remained  to  be 
determined  how  any  requisite  number  of  micro-organisms  could 
remain  stationary  on  certain  unsheltered  surfaces  of  the  teeth 
where  decay  was  seen  to  occur  for  a  sufiicient  time  to  form  their 


DENTAL    CARIES.  33 

acid  and  dissolve  the  enamel  ■without  being  washed  away  by  the 
fluids  of  the  mouth. 

It  is  found  in  the  cultivation  of  micro-organisms  that  there  are 
certain  forms  which  in  the  progress  of  their  development  form  a 
substance  allied  in  physical  appearance  to  gelatin,  and  are  there- 
fore called  gelatin-forming  micro-organisms.  It  is  to  this  class 
that  the  micro-organisms  of  caries  belong,  and,  in  pursuance  of 
their  function,  they  produce  on  the  surface  of  the  tooth  a  gelatin- 
ous film,  under  cover  of  which  they  are  enabled  to  work  their  de- 
structive processes  undisturbed.  This  film  is  sufficiently  adherent 
to  the  tooth  to  withstand  the  ordinary  rinsing  of  fluids  in  the  mouth, 
and  thus  we  see  decay  taking  place  in  positions  where  the  micro- 
organism itself  would  be  washed  away  if  left  unprotected.  But 
the  film  may  be  broken  up  and  detached  by  any  appreciable 
amount  of  friction,  such,  for  instance,  as  the  friction  of  food  in 
mastication,  where  that  process  is  exercised  to  its  fullest  functional 
activity.  Accordingly,  we  may  look  for  the  greatest  ravages  of 
decay  in  surfaces  of  the  teeth  not  subject  to  the  friction  of  food, 
as  the  proximal  surfaces,  or  in  sheltered  localities  formed  by  de- 
velopmental defects,  as  in  the  fissures  or  pits  where  the  micro- 
organisms may  work  unmolested. 

The  legitimate  office  of  the  tooth-brush,  the  dental  floss,  or  the 
toothpick  may  be  more  intelligently  comprehended  when  the 
character  and  significance  of  this  gelatinous  film  is  understood. 
If  that  film  can  be  kept  from  the  teeth  it  would  seem  that  we  have 
small  need  for  worry  over  the  problem  of  controlling  dental  caries, 
and  in  this  connection  our  advice  to  patients  as  to  the  proper  time 
to  brush  the  teeth  should  be  governed  largely  by  a  recognition  of 
the  facility  with  which  this  film  may  form  under  favorable  con- 
ditions. If  we  find  a  mouth  where  decay  is  progressing  rapidly, 
showing  active  work  on  the  part  of  the  micro-organisms,  we  should 
advise  frequent  attention  to  the  teeth,  so  as  to  interfere  as  largely 
as  possible  with  the  formation  of  these  films.  Brushing  the  teeth 
three  times  a  day  under  these  conditions  will  not  be  too  much,  but 
the  time  of  all  others  when  it  would  seem  necessary  to  go  over 
every  surface  carefully  with  brush,  pick,  or  floss  is  just  before  re- 


64:  PKINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

tiring,  when  the  fluids  of  the  month  are  to  remain  qniet  for  the 
greatest  length  of  time  in  the  twenty-four  hours,  and  the  micro- 
organisms are  given  the  best  opportunity  for  work. 

Dr.  Williams's  notable  achievement  in  clearing  up  this  subject 
of  the  modus  operandi  of  dental  decay  relates  to  the  fact  that  he- 
succeeded  in  grinding  sections  of  the  teeth  sufficiently  thin  for 
microscopical  examination,  and  at  the  same  time  retaining  in  place 
this  gelatinous  film  with  its  nest  of  micro-organisms  thereby  glued 
to  the  enamel,  and  showing  plainly  the  action  of  the  acid  upon  the 
tooth-tissue.  This  was  the  missing  link  which  changed  conjec- 
ture into  certainty,  and  developed  one  of  the  most  significant  fac- 
tors in  the  institution  of  dental  caries.  It  would  from  this  demon- 
stration seem  necessary  for  this  film  to  form  in  order  to  have  caries 
begin  as  we  usually  find  it,  and  therefore  any  influence  which  tends 
to  prevent  its  formation  would  to  that  extent  act  as  a  prophylactic. 

As  has  been  intimated,  cleanliness  of  the  teeth  may  be  con- 
sidered an  important  adjunct  in  checking  the  inroads  of  the  micro- 
.organisms,  but  unless  it  is  faithfully  pursued,  and  the  cleansing  of 
suflicient  frequency,  it  will  not  be  found  wholly  effective  in  pre- 
venting caries  in  mouths  where  the  tendency  to  its  development  is 
favorable.  It  is  a  question  of  hours  instead  of  days  when  these 
micro-organisms  can  form  gelatin  and  produce  acid,  and  a  mouth 
may  be  cleansed  as  perfectly  as  possible  once  in  twenty-four  hours 
and  yet  give  the  micro-organisms  ample  time  to  act  in  the  inter- 
vals, provided  the  conditions  are  suitable  to  their  progress. 

This  question  of  condition  is  the  keynote  of  immunity  or  sus- 
ceptibility, and,  with  our  present  knowledge,  it  would  seem  that 
the  influence  of  the  fluids  of  the  mouth  on  the  formation  or  dis- 
solution of  this  micro-organic  film  has  more  to  do  with  the  advance 
or  retardation  of  dental  caries  than  any  other  single  factor.  If  in 
a  certain  mouth  the  conditions  are  such  that  the  micro-organisms 
are  unable  to  form  their  film,  and  thereby  afford  themselves  pro- 
tection in  the  progress  of  their  work,  we  may  be  hopeful  that  the 
ravages  of  decay  in  that  mouth  will  not  be  serious;  but  if,  on  the 
contrary,  the  conditions  seem  to  favor  the  formation  of  these  films, 
we  must  consider  such  a  case  susceptible. 


DENTAL    CAKIES.  35 

It  was  formerly  the  prevalent  idea  in  the  profession  that  the 
structure  of  the  teeth  had  much  to  do  with  the  liability  to  decay; 
that  teeth  which  were  found  to  be  extensively  attacked  must  be 
considered  of  poor  structure,  while  those  practically  free  from 
caries  were  accordingly  accounted  as  being  of  good  structure.  The 
investigations  of  Dr.  Black  into  the  physical  character  of  the  teeth 
proved  that  this  position  was  untenable ;  that  there  was  really  much 
less  variation  in  the  structure  of  the  teeth  than  had  been  supposed, 
and  that  what  little  difference  did  exist  seemed  to  have  almost  no 
relation  to  the  liability  to  decay.  It  simply  resolved  itself  down  to 
a  question  of  environment.  If  teeth  decayed  rapidly  in  a  mouth 
it  was  because  the  conditions  in  that  mouth  were  favorable  to  the 
agencies  which  bring  about  decay,  and  not  because  the  teeth  were 
necessarily  of  poor  structure;  and  it  is  confidently  believed  that 
along  this  line  of  investigation  lies  the  only  hope  of  the  profession 
toward  the  solution  of  the  problem  of  preventing  dental  caries.  If 
by  any  means  we  are  eventually  able  to  bring  about  such  a  condi- 
tion in  the  mouth  that  the  micro-organism  of  decay  cannot  therein 
find  a  suitable  habitat  for  the  full  performance  of  its  acid-produc- 
ing function,  or  rather  if  we  can  so  medicate  the  mouth  that  it  will 
be  found  impossible  for  the  micro-organism  to  form  its  gelatinous 
film  in  contact  with  the  tooth,  we  can  to  that  extent  control  decay. 
Either  one  of  two  things  seems  necessary:  that  we  create  a  condi- 
tion inimicable  to  the  formation  of  the  film,  or  that  we  provide  a 
solvent  which  is  capable  of  dissipating  it  as  fast  as  it  forms.  In 
order  to  do  this  we  must  first  learn  more  of  the  nature  of  this  film 
and  the  conditions  suitable  to  its  growtli,  and  it  is  in  this  relation 
that  future  study  should  be  directed. 

Til  at  conditions  exist  in  the  mouth  which  influence  this  matter 
for  good  or  ill  is  clearly  evident  from  a  clinical  study  of  cases. 
\Vc  find  that  then;  is  in  the  same  individual  a  great  variation  at 
different  periods  in  the  tendency  to  caries,  and  since  we  have 
learned  that  the  tooth-tissue  is  not  so  fluctuating  in  its  character, 
arid  does  not  grow  hard  and  soft  so  readily  as  was  formerly  sup- 
jjosed,  we  nnist  look  to  changes  in  the  conditions  surrounding  the 
ffftli  to  account  for  the  varying  manifestations  of  the  disease. 


ob  PBTSCIPJLIIS    A3T)    PEACTICi:    OF    iTIirS"G-    TEETH. 

A  close  study  of  cases  in  practice  "will  rereal  some  rather 
marked  instances  of  periodical  snsceptibilily  and  inimnnity,  and 
the  history  of  these  cases  Trill  often  prove  not  only  of  the  greatest 
ralne^  but  also  a  source  of  the  ntmost  satisfaction  and  encottrage- 
ment.  The  recital  at  this  point  of  a  single  case  from  practice  may 
serve  to  indicate  the  common  mn  of  snch  climcal  histories  where 
the  disease  is  follo"wed  np  vigorously  by  the  dentist.  This  case 
seemed  a  desperate  one.  a  case  in  "vrhich,  tmder  ordinary  circnm- 
stances,  many  of  the  teeth  wonld  probably  have  been  lost  if  any 
half-hearted  methods  of  treatment  had  been  employed.  And  yet 
the  final  outcome  "was  snch  as  may  be  confidently  expected  in  nine 
cases  out  of  ten  where  the  dentist  is  in  earnest  vdth  his  work  and 
has  an  intelligent  conception  of  the  possibihties  of  an  approaching 
immunity. 

The  patient  was  a  girl  of  eight  or  nine  when  brought  to  the 
dentist  by  her  parents,  and  the  first  permanent  molars  were  already 
affected.  Trom  this  time  forward  during  the  next  six  or  seven  years 
the  activity  of  the  carious  process  in  that  mouth  was  appalling. 
Teeth  would  decay  on  their  journey  through  the  gnnis  in  eruption: 
recurrences  of  caries  around  fillings  would  take  place  with  discour- 
aging frequency,  and  new  cavities  would  spring  up  seemingly 
almost  in  a  night.  The  dentist  did  the  best  he  could,  which  he 
freely  acknowledges  was  not  very  good,  owing  to  the  hypersensi- 
tiveness  of  the  dentine  wherever  decay  occurred.  But  an  honest 
effort  was  made  to  fight  back  the  intruder,  and  to  encourage  the 
patient  to  persevere  in  the  face  of  the  most  disheartening  condi- 
tions. Grold  was  out  of  the  question,  and  resort  was  accordingly 
had  to  amalgam,  the  cements,  and  gutta-percha.  Even  then  the 
cavities  were  often  not  well  prepared,  through  fear  that  radical 
methods  of  treatment  would  prove  too  great  a  tax  on  the  patient 
and  tip  the  balance  in  the  wrong  direction,  so  that  she  would  give 
up  the  work  in  despair  and  let  the  teeth  go.  At  times  during 
those  trying  years  it  seemed  almost  a  hopeless  case,  and  yet  the 
sacrifice  of  losing  a  set  of  teeth  which  in  appearance  were  really 
beautiful  was  too  great  to  be  thought  of.  The  patient  was  in- 
structed to  report  for  examination  every  three  months.     Some- 


DEXTAL    CAKIES.  37 

times  she  would  appear  before  the  allotted  time  with  the  stereo- 
typed remark,  "Doctor,  I  am  afraid  there  are  other  cavities  com- 
ing." And  they  nsually  were  coming.  It  grew  to  be  something 
of  a  dread  to  have  this  patient's  name  announced,  and  yet  she  was 
never  met  with  anything  but  the  most  encouraging  demeanor,  and 
the  idea  was  constantly  schooled  into  her  that  those  teeth  must  be 
saved  at  any  cost. 

This  kind  of  warfare  was  kept  up  till  she  was  sixteen  or  seven- 
teen, when  a  period  of  a  year  elapsed  mthout  her  reporting  at  the 
office,  and  the  natural  inference  was  that  she  had  finally  yielded  to 
what  seemed  the  inevitable  and  was  allowing  the  teeth  to  go  by 
default.  But  one  day  she  came  again  with  a  request  to  have  her 
teeth  examined,  saying  that  she  had  experienced  no  trouble  with 
them  in  the  interval,  but  thought  they  must  by  this  time  need 
attention.  The  first  glance  at  the  teeth  revealed  a  condition 
entirely  different  from  anything  that  had  ever  been  noted  in  that 
mouth  before,  and  the  dentist  realized  instantly  that  the  battle 
had  at  last  been  won.  The  surfaces  of  the  teeth  were  clean  and 
bright,  and  the  gums  hard  and  normal.  When  questioned  as  to 
whether  she  had  given  the  teeth  particular  attention  since  her 
last  visit  to  the  office,  the  patient  said  that  she  was  not  conscious 
of  having  done  more  than  the  ordinary. 

Since  then,  now  more  than  five  years,  there  has  been  almost  no 
necessity  for  dental  service  in  that  mouth,  except  to  replace  with 
gold  the  worn-out  cement  and  gutta-percha  fillings  one  by  one  as 
they  failed.  To-day  the  young  lady  has  her  full  complement  of 
natural  teeth,  without  even  the  necessity  of  having  had  any  of 
them  croAvned.  The  posterior  teeth  are  most  inartistically  patched 
and  plastered  with  amalgam,  but  from  an  anterior  view  this  young 
lady  would  be  credited  by  the  average  observer  with  having  an 
exceptionally  good  and  an  exceptionally  beautiful  set  of  teeth. 

Such  a  result  as  this — and  the  case  here  recorded  is  by  no  means 
an  isolated  one — should  prove  of  the  greatest  possible  encourage- 
ment to  both  operator  and  patient,  and  should  stimulate  the  practi- 
tioner to  take  vigorously  in  hand  even  the  most  unpromising  case 
and  fight  back  the  disease,  no  matter  how  active  its  ravages  appear 


38  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

to  be.  Immunity  does  not  always  develop  so  suddenly  or  so  com- 
pletely as  in  this  instance;  in  fact,  there  are  some  patients  who 
never  seem  to  become  immune,  but  in  the  vast  majority  of  indi- 
viduals we  may  confidently  look  for  a  very  appreciable  change  in 
the  liability  to  decay  as  age  advances  from  childhood  to  middle 
life,  provided  we  take  stringent  measures  to  control  the  difiiculty. 
It  would  seem  from  clinical  observation  that  the  period  of 
immunity  is  hastened  by  an  active  campaign  against  the  develop- 
ment of  caries,  whereby  the  occurrence  of  large  cavities  is  avoided 
and  the  teeth  are  kept  comfortable  for  the  maintenance  of  a  full 
functional  activity.  ISTeglected  cavities  in  teeth  invite  decay  in 
adjacent  teeth,  and  wherever  the  function  of  mastication  is  inter- 
fered with  through  sensitiveness  the  teeth  in  that  locality  are 
dej)rived  of  the  adequate  friction  to  keep  them  free  from  adhesive 
materials  of  a  character  calculated  to  bring  about  decay.  The 
highest  degree  of  health  in  the  mouth,  as  elsewhere,  is  to  be 
obtained  only  by  the  requisite  exercise  of  all  the  functions,  and 
this  cannot  ensue  where  the  teeth  are  sensitive  from  decay  or 
where  they  are  not  adequately  used  in  mastication.  A  close  study 
should  be  made  to  determine  whether  or  not  the  patient  masticates 
fully,  and  if  it  is  found  that  this  function  is  not  properly  per- 
formed the  patient  should  be  vigorously  schooled  into  an  observ- 
ance of  its  necessity. 

It  is  of  the  very  greatest  importance,  if  immunity  is  to  be  estab- 
lished early  in  life,  that  the  most  strenuous  efforts  be  made  to 
check  the  disease  in  its  incipiency,  and  to  keep  a  watchful  eye 
over  the  general  condition  of  the  mouth  to  see  that  the  functions 
are  normally  active.  ISTor  must  it  be  assumed  that  even  where  an 
apparent  immunity  has  been  once  established  the  case  will  invari- 
ably remain  permanently  immune.  Relapses  seem  as  likely  to 
occur  here  as  in  other  diseases,  though  they  are  usually  manifested 
in  a  different  manner,  and  they  do  not  necessarily  follow  the 
initial  attack  for  some  years.  In  the  case  just  recorded  the  proba- 
bility is  that,  even  after  this  long  period  of  practical  immunity,  if 
the  young  lady  gets  married  and  is  called  upon  to  pass  through  all 
the  concomitant   vicissitudes   of  motherhood,   those   treacherous 


DENTAL    CARIES. 


39 


little  micro-organic  dogs  of  war  will  be  turned  loose  upon  her  teeth 
once  more,  and  there  will  be  another  contest  for  supremacy. 
Decay  will  commence  again  in  a  manner  to  discourage  any  practi- 
tioner who  has  not  a  well-defined  idea  as  to  the  usual  manifesta- 
tions of  periodical  susceptibility  and  immunity,  but  to  one  who 
is  accustomed  to  watching  these  cases  there  can  be  only  one  mind 
as  to  the  final  outcome,  provided  the  proper  course  is  pursued.  If 
the  case  is  met  in  a  vigorous  manner,  and  the  teeth  kept  comforta- 
ble by  checking  the  decay  in  its  earliest  stages,  the  attack  will  soon 
pass  by  and  the  teeth  be  saved.  In  some  of  these  relapses,  when 
the  circumstances  are  such  that  the  patient  is  unable  to  apply  to 
the  dentist  with  sufficient  frequency,  a  pulp  is  occasionally  lost  and 
a  tooth  sometimes  breaks  down  to  the  degree  of  requiring  a  cro\vn, 
but  this  is  usually  the  extent  of  the  disaster,  and  the  mouth  is  still 
xaaintained  in  full  functional  usefulness. 

As  has  been  intimated,  it  is  the  rarest  thing  to  find  a  case  where 
the  carious  process  is  uniformly  and  progressively  active  through 
life  if  anything  like  a  reasonable  attempt  is  made  to  check  it. 
There  are,  of  course,  many  cases  where  the  teeth  are  lost  one  after 
another  till  all  are  gone,  even  at  an  early  age  of  the  patient,  but 
these  are  usually  cases  where  no  adequate  attempt  has  been  made 
to  check  the  disease,  and  where  the  carious  proce&s  has  had  the 
most  favorable  opportunity  to  advance. 

In  the  light  of  what  we  now  know,  it  may  be  laid  down  as  a 
■conservative  statement  to  say  that  with  proper  attention  the  teeth 
of  most  individuals  may  be  saved  through  life,  so  far  as  decay  is 
concerned,  and  it  is  confidently  believed  that  an  intelligent  concep- 
tion on  the  part  of  the  profession  of  the  phenomena  presented  by 
immunity  and  susceptibility  will  add  materially  to  the  possibility 
of  such  a  consummation.  If  tlie  operator's  attention  is  constantly 
directed  to  the  conditions  surrounding  the  teeth,  rather  than  fall- 
ing back  on  the  old  fallacy  that  the  tendency  to  decay  is  influenced 
by  changes  in  the  structure  of  the  teeth,  and  thus  entirely  out  of 
his  reach,  it  will  place  him  in  a  more  enlightened  relation  to  the 
matter,  and  he  will  ])C  better  equipped  to  meet  the  emergency  and 
overcome  it.    That  there  is  a  difference  in  the  density  of  teeth  need 


40  PRINCIPLES    AND    PEACTICE    OF    FILLING    TEETH. 

not  be  argued,  and  tliat  there  is  a  wide  variation  in  the  behavior  of 
teeth  under  the  action  of  cutting  instruments  no  man  of  long 
clinical  experience  will  attempt  to  deny.  Some  teeth  may  be  cut 
and  chiseled  away  very  readily,  while  others  appear  to  cut  like- 
flint,  and  will  dull  the  sharpest  and  hardest  instrument;  but  a 
close  observation  of  these  cases  would  seem  to  indicate  that  the- 
difference  in  resisting  power  to  instruments  is  confined  largely  to 
the  enamel,  and  that  this  difference  is  due  more  to  the  variation  in 
the  arrangement  of  the  enamel-rods  than  to  variations  in  density- 
In  some  teeth  the  rods  stand  straight,  regular,  and  parallel;  in 
others  they  are  wavy  and  exceedingly  irregular  in  their  course. 
It  is  the  difference  between  straight-grained  maple  and  bird's-eye- 
maple.  The  axe  will  readily  split  straight-grained  maple,  while 
bird's-eye  maple  is  stoutly  resistant.  It  is  practically  the  same- 
with  the  different  kinds  of  enamel.  But  that  there  is  really  little 
variation  in  the  liability  to  decay  of  the  different  classes  of  tooth- 
tissue  Dr.  Black's  investigations  proved  most  conclusively.  The 
hardest  tooth  that  was  ever  developed,  if  placed  in  a  mouth  where 
the  micro-organisms  are  permitted  to  form  their  gelatinous  masses 
and  produce  their  characteristic  acid,  will  promptly  be  attacked 
by  caries,  while  a  tooth  seemingly  friable  in  structure  will  remain 
free  from  caries  in  a  mouth  where  the  conditions  are  unfavorable 
to  such  action.  It  thus  seems  to  be  wholly  a  question  of  environ- 
ment, though  it  is  not  here  intended  to  intimate  that  the  denser 
tooth  will  break  down  as  rapidly  under  the  carious  process  when  it 
has  once  started  as  will  the  one  of  less  resisting  structure. 

That  well-formed  enamel  is  capable  of  being  attacked  is  amply 
demonstrated  by  the  location  of  many  of  the  cavities  we  find  in  the' 
mouth.  The  proximal  surfaces  of  the  teeth  are  probably  attacked 
as  often  as  any  other,  and  at  this  point  we  do  not  ordinarily 
look  for  defects  in  the  tooth-structure.  There  are  no  pits  or  fis- 
sures, and  the  enamel  is  laid  on  as  perfectly  as  at  other  surfaces- 
where  decay  seldom  occurs.  The  reason  we  find  cavities  on  the 
proximal  surfaces  is  because  of  the  environment,  the  position 
being  sheltered  and  free  from  the  friction  which  interferes  with 
the  micro-organisms  on  exposed  surfaces.     Then,  again,  we  leam 


DENTAL    CAKIES.  41 

many  an  instructive  lesson  in  the  examination  of  developmental 
defects  in  tooth-tissue.  We  ordinarily  look  for  cavities  at  points 
where  the  enamel  has  failed  in  a  continuity  of  structure,  leaving 
pits  or  fissures,  and  in  a  mouth  subject  to  caries  we  usually  find 
initial  decay  at  these  points.  But,  on  the  other  hand,  we  fre- 
quently see  cases  where,  on  account  of  immunity,  the  teeth  go  for 
a  lifetime  containing  deep  fissures  entirely  through  the  enamel 
without  decay  occurring  in  any  of  them.  These  are  phenomena 
which  should  command  the  closest  attention  of  the  profession,  to 
the  end  that  we  become  familiar  with  all  of  the  manifestations  of 
dental  decay  and  have  an  intelligent  conception  of  its  true  nature. 

If  it  be  finally  proved  beyond  doubt,  as  would  at  present  seem 
to  be  the  case,  that  the  question  of  condition  is  the  chief  factor  in 
this  disease,  then  it  devolves  upon  us  to  know  what  this  condition 
is,  and  to  treat  cases  scientifically  to  control  condition.  As  has 
already  been  intimated,  we  at  present  know  very  little  about  this 
subject  of  condition.  We  cannot  tell  what  particular  elements 
there  are  in  the  fluids  of  a  certain  mouth  tending  to  favor  the 
formation  of  these  micro-organic  films,  which  seem  to  be  the  main 
instrumentality  of  the  destructive  process,  nor  do  we  know  what 
constitutes  a  condition  unfavorable  to  them.  We  are  not  even 
clear  in  our  clinical  observations  as  to  surface  indications  which 
may  lead  us  to  judge  whether  a  mouth  is  susceptible  or  immune, 
except  as  we  see  cavities  or  do  not  see  them.  And  yet,  even  with 
our  present  knowledge,  it  should  not  be  necessary,  if  we  are  truly 
observant,  for  us  to  see  actual  caries  in  order  to  know  that  a  mouth 
is  susceptible.  There  are  unmistakable  evidences  present  in  some 
mouths  which  indicate  the  activity  of  the  carious  process  to  one 
Avho  has  closely  studied  the  matter,  and  yet  to  attempt  to  describe 
these  indications  so  that  they  will  be  intelligible  to  others  seems 
not  to  be  easy  of  accomplishment.  They  relate  more  to  an 
intuitive  perception  of  general  conditions  on  the  part  of  the 
observer,  rather  than  to  any  definite  landmarks  in  the  mouth  that 
may  be  described. 

It  is  with  this  limitation  clearly  in  mind  that  a  few  hints  are 
herein  offered  for  observation,  with  the  suggestion  that  each  practi- 


42  PEIS'CIPLES    AND    PRACTICE    OF    FILLHSTG    TEETH. 

tioner  take  up  the  study  of  this  matter  in  his  own  experience  till 
lie  secures  an  intelligent  basis  for  judgment. 

A  mouth  that  is  acutely  susceptible  will  ordinarily  present  an 
Tinkempt  appearance;  not  necessarily  resulting  in  the  presence  of 
salivary  calculus,  but  apparently  indicating  that  the  teeth  are  not 
well  cared  for.  Accumulations  of  a  soft  nature  may  be  scraped 
from  the  surfaces,  as  if  the  patient  had  just  arisen  from  a  meal  of 
pasty  materials  and  had  not  even  rinsed  the  mouth.  The  fluids 
around  the  teeth  seem  to  contain  much  thick  mucus,  which  ren- 
ders the  semi-solid  substances  adhesive  to  the  surfaces  of  the 
■enamel,  though  the  saliva  on  entering  the  mouth  at  the  orifices  of 
the  ducts  may  appear  of  normal  fluidity.  If  such  a  patient  is 
handed  a  glass  of  water  and  asked  to  rinse  the  mouth  thoroughly, 
it  will  be  found  that  after  the  attempt  is  made  the  teeth  are  left 
with  these  glutinous  accretions  still  clinging  to  them.  ]*Tothing 
but  a  very  vigorous  rubbing  will  leave  the  teeth  reasonably  smooth, 
and  even  after  the  most  thorough  cleansing  it  is  only  a  matter  of 
a  few  hours  when  they  are  found  coated  again.  The  first  impres- 
sion on  looking  into  such  a  mouth  is  that  the  patient  ignores  dental 
hygiene  altogether,  and  yet  some  of  these  cases  are  at  least  as  well 
cared  for  as  the  average.  It  simply  seems  an  almost  impossible 
task  to  keep  the  teeth  free  from  accumulations.f  If  a  thin,  flexible 
scaler  be  passed  along  the  sheltered  surfaces  of  the  teeth  it  will 
almost  invariably  peel  up  a  film  of  gelatinous  material,  and  even 
the  occlusal  surfaces  of  such  teeth  are  never  found  as  highly 
polished  as  ordinarily.  The  teeth  seem  to  invite  the  adhesion  of 
materials  as  if  the  enamel  were  roughened,  and  in  connection  with 
this  the  gums  are  usually  found  more  or  less  hypertrophied,  so  that 
the  festoons  creep  up  over  the  teeth  more  prominently  than  normal 
and  bleed  on  the  slightest  touch.  This  is  frequently  noted  in 
such  cases,  even  where  there  are  no  calcareous  deposits  to  account 
for  it.  A  mouth  in  this  condition  should  be  watched  very  closely 
with  the  expectancy  of  caries  if  the  condition  persists  for  any  time. 

The  change  from  this  to  a  state  of  immunity  is  usually  marked 
by  a  general  clearing  up  of  the  fluids  of  the  mouth,  with  decreased 
viscidity  and  tenacity.     The  mouth  can  be  rinsed  tolerably  clean 


DENTAL    CARIES.  43 

Tvitbout  the  use  of  the  brush,  and  there  is  an  appearance  of  cleanli- 
ness, as  if  better  care  were  taken  of  the  teeth  even  in  cases  where 
no  change  has  been  made  in  the  patient's  habits  in  this  regard. 
There  is  little  tendency  for  the  accumulation  of  foreign  material 
about  the  teeth,  and  the  impression  on  the  observer  is  that  there 
seems  to  be  some  kind  of  solvent  present  in  the  mouth  which  keeps 
the  fluids  clear  and  prevents  the  formation  of  the  glutinous  masses 
seen  during  the  susceptible  period.  Coincident  with  this  the  gums 
shrink  to  their  normal  form  and  become  firm  and  pink,  and  do  not 
readily  l)leed  on  pressure. 

AVhen  the  operator  observes  these  changes  going  on  in  a  mouth 
that  has  been  causing  him  unlimited  anxiety,  he  may  feel  much 
the  same  sense  of  elation  which  comes  over  a  physician  when  he 
finds  a  patient  who  has  been  suffering  from  a  high  and  stubborn 
fever  suddenly  bursting  out  into  a  generous  perspiration.  The 
tension  is  relieved,  and  for  the  time  at  least  the  dogs  of  war  are 
chained,  so  that  both  operator  and  patient  may  have  a  chance  to 
breathe. 

The  practical  lesson  of  this  whole  study  of  susceptibility  and 
immunity  resolves  itself  down  to  the  fact  that  an  operator  is  never 
justified  in  allowing  even  the  worst  case  of  dental  caries  to  go  by 
default.  He  should  institute  the  most  vigorous  proceedings 
against  the  enemy,  with  the  idea  ever  in  mind  that  sooner  or  later 
the  kindly  ofiices  of  a  beneficent  nature  will  intercede  and  help  him 
win  the  battle.  It  is  his  duty  in  the  darkest  hours  of  these  trying 
cases  to  explain  to  the  patient  as  clearly  as  he  ma}^  the  theory  of 
immunity,  and  offer  such  encouragement  as  an  understanding  of 
this  phenomenon  will  suggest.  By  so  doing  he  will  often  carry 
the  patient  through  a  disheartening  experience,  which  otherwise 
would  prove  sufficient  to  cause  a  total  neglect  and  loss  of  the  teeth. 


44  PEINCIPLES    AND    PEACTICE    OF    FILLING    TEETH. 

CHAPTEK   III. 

EXAMINATION  OF  THE  TEETH  FOR  CAEIES. 

When  a  patient  selects  a  dentist  and  places  tlie  teetli  in  his 
charge,  it  is  the  dentist's  duty  to  make  a  careful  examination  of  the 
teeth  at  intervals  sufficiently  frequent  to  enable  him  to  keep  per- 
fect control  of  them  and  prevent  the  possibility  of  caries  even 
approaching  the  pulp,  much  less  causing  the  loss  of  a  tooth.  There 
should  be  a  definite  understanding  with  each  new  patron  with 
regard  to  the  mutual  responsibility  existing  between  operator  and 
patient,  the  former  assuming  the  obligation  of  saving  the  teeth 
and  keeping  them  in  a  condition  of  functional  utility,  barring 
accidents  or  unforeseen  complications,  provided  the  latter  will 
faithfully  report  for  examination  at  stated  times  to  be  suggested 
by  the  dentist.  A  clear  understanding  of  this  nature  will  not 
only  stimulate  the  practitioner  to  his  best  endeavor,  but  will  place 
the  patient  in  such  a  relation  to  the  matter  as  to  lead  to  increased 
respect  and  appreciation  of  dental  service.  It  will  also  establish 
a  professional  and  personal  sentiment  between  the  two  which  will 
tend  finally  to  a  series  of  friendships  in  the  conduct  of  a  practice 
calculated  to  prove  one  of  the  most  pleasant  features  of  profes- 
sional life. 

As  to  the  frequency  with  which  patients  shall  be  instructed  to 
apply  for  examination,  the  dentist  must  judge  on  the  basis  of  a 
study  of  each  case  in  its  relation  to  the  evident  tendency  or  other- 
mse  to  decay  in  that  mouth.  In  some  particular  cases  where 
the  carious  process  seems  acutely  active,  the  teeth  should  be  seen 
as  often  as  every  second  month,  while  in  others  they  may  safely 
go  six  months.  But  in  no  case  where  decay  has  once  shown  itself 
should  the  patient  fail  to  apply  at  least  twice  a  year  for  examina- 
tion, and  in  the  mean  time  should  report  immediately  on  the  ap- 
pearance of  any  suspicious  sensitiveness  in  the  teeth.  With 
patients  who  are  inclined  to  neglect  or  forget  these  examinations 
the  dentist  should  have  an  understanding  whereby  he  shall  notify 
them  at  regular  intervals  to  appear  for  inspection.     Appreciative 


EXAMINATION    OF    THE    TEETH    FOE    CARIES,  45 

patients  take  very  kindly  to  the  idea  of  these  regular  notices  when 
they  understand  the  motive. 

All  operative  procedures  upon  the  teeth  should  be  pursued  in  a 
systematic  and  orderly  sequence,  even  one  apparently  so  simple  as 
the  examination  for  caries.  When  it  is  considered  that  each  tooth 
has  five  surfaces,  any  one  of  which  may  be  decayed,  it  will  be 
seen  that  to  properly  examine  an  entire  set  of  teeth  involves  more 
than  a  casual  glance  into  the  mouth,  such  as  is  often  made  to  pass 
muster  for  an  examination.  An  operator  owes  it  to  his  patient 
not  to  overlook  the  slightest  defect,  particularly  in  a  mouth  where 
caries  is  prevalent,  and  to  this  end  every  surface  should  be  brought 
under  critical  inspection.  To  accomplish  this  at  the  expenditure 
of  the  least  time  the  operator  should  have  some  definite  starting 
point  in  the  mouth,  and  proceed  from  this  in  regular  order  till  the 
entire  set  of  teeth  has  been  covered.  A  convenient  place  to  begin 
is  the  left  lower  third  molar,  and  from  this  to  the  next  tooth  in 
line  till  the  right  lower  third  molar  is  reached,  when  the  mirror 
may  be  turned  to  the  right  upper  third  molar,  and  all  the  upper 
teeth  examined,  ending  with  the  left  upper  third  molar.  In  this 
way  no  tooth  need  be  missed,  and  the  least  possible  time  is  con- 
sumed in  the  examination. 

Appliances  for  Examining  the  Teeth. 
These  should  consist  of  a  mouth-mirror,  an  exploring  instru- 
ment, and  some  unwaxed  floss  silk.  The  mouth-mirror  is  an 
appliance  which  has  the  widest  possible  range  of  usefulness  in 
operative  dentistry.  It  begins  with  the  examination  of  the  teeth, 
and  ends  only  with  a  final  inspection  of  the  completed  operation. 
The  dentist  should  early  acquire  the  closest  familiarity  with  this 
appliance,  so  that  it  becomes  second  nature  with  him  to  constantly 
hold  it  in  his  left  hand  while  operating.  By  its  use  he  is  able  to 
discover  defects  in  the  teeth  which  his  unaided  eye  would  never 
reveal,  and  when  he  has  attained  a  thorough  mastery  of  it  he  can 
perform  many  operations  through  the  agency  of  the  image  pre- 
sented in  the  glass  without  the  necessity  of  stooping  over  to  look 
directly  into  the  mouth.     In  any  operation  on  the  molars  or  bi- 


46  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

cuspids,  even  where  direct  vision  is  possible,  the  work  is  greatly 
facilitated  by  reflecting  the  light  fully  upon  the  operation  with  the 
mirror. 

For  examining  the  teeth  this  reflected  light  is  very  valuable,  in 
the  evidence  it  often  gives  of  caries  on  the  proximal  surfaces 
where  the  probe  fails  to  find  any  defect.  Sometimes  decay  occurs 
so  near  the  contact  point  that  the  exploring  instrument  cannot 
enter  it,  but  by  throwing  the  light  upon  the  teeth  the  enamel  will 
usually  show  a  different  color  from  normal  tooth-tissue.  This 
relates  to  a  dead  white  appearance  which  is  distinctive  in  character, 
and  readily  recognized  by  an  experienced  operator.  When  this 
appearance  is  noted,  and  there  seems  no  possibility  of  gaining 
entrance  to  the  cavity  with  the  finest  probe,  the  question  of 
whether  there  is  decay  or  not  may  often  puzzle  the  beginner.  It 
is  here  that  the  floss  silk  is  especially  useful.  If  drawn  between 
the  proximal  surfaces  of  the  teeth  where  caries  is  present  it  will 
usually  drag  and  fray  against  the  rough  margins  of  the  cavity, 
instead  of  passing  the  contact  points  with  a  snap,  as  is  the  case 
where  the  teeth  are  normal.  In  some  instances  the  floss  will 
be  severed  completely,  and  when  such  is  the  case  there  can  l^*e 
no  longer  any  doubt  about  the  presence  of  a  cavity. 

The  exploring  instrument  is  especially  useful  for  investigating 
the  fissures  and  pits  of  the  occlusal  surfaces,  and  for  probing 
around  the  teeth  generally  wherever  the  light  from  the  glass  can- 
not penetrate.  It  should  be  very  fine  and  sharp  at  the  point,  but 
with  suflicient  bulk  at  the  shank  to  make  it  reasonably  rigid. 

As  to  the  best  kind  of  mirror  for  ordinary  use  in  the  mouth,  it 
may  be  stated  incidentally  that  a  plane  mirror  is  preferable  to  a 
magnifying  mirror.  The  latter  so  distorts  the  image  as  to  be 
very  misleading,  while  a  plane  mirror  always  gives  the  true  image. 
In  critical  examinations,  where  the  image  requires  enlargement, 
a  good  magnifying  glass  is  very  useful,  but  never  a  magnifying 
mirror. 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS.  4T 

OHAPTEK    lY. 

EXCLUSION  OF  3I0ISTUKE  DURING  OPERATIONS. 

One  of  tlie  chief  hindrances  to  the  execution  of  perfect  work  in 
the  mouth  is  the  saliva,  and  the  problem  accordingly  presents  itself 
of  keeping  the  teeth  free  from  moisture  during  operations.  Vari- 
ous methods  have  been  employed  for  this  purpose,  but  in  the 
majority  of  cases  the  only  effective  means  is  by  the  use  of  the 
rubber  dam  introduced  years  ago  by  Dr.  Barnum.  Previous  to 
the  introduction  of  the  rubber  dam  the  main  reliance  was  upon 
napkins,  and,  while  many  operators  became  very  proficient  in  their 
use,  there  was  never  the  security  that  is  readily  afforded  by  the 
dam.  Every  operator  should  become  an  expert  in  the  application 
of  the  dam,  to  the  end  that  he  may  avail  himself  of  its  advantages 
in  all  difficult  or  complicated  cases  of  treatment  or  filling.  The 
dam  is  not  used  as  much  as  it  should  be  by  many  operators,  on 
account  of  a  failure  to  thoroughly  master  its  ready  application, 
and  in  many  cases  it  is  made  to  work  unnecessary  hardships  on  the 
patient  through  faulty  methods  of  adjustment.  It  is  sufficiently 
unpleasant  to  most  people,  even  when  skillfully  used,  without  add- 
ing to  the  discomfort  by  bungling  or  awkwardness. 

'J'he  greatest  consideration  should  invariably  be  exercised  on 
the  patient's  behalf;  not  only  in  the  adjustment  of  the  dam  itself, 
but  in  the  use  of  accessories,  such  as  clamps,  ligatures,  dam-holder, 
weights,  etc.  Adequate  protection  to  the  patient's  clothing  from 
the  overflow  of  the  saliva,  particularly  when  operating  upon  the 
lower  teeth,  should  be  provided  in  the  way  of  saliva  ejectors,  nap- 
kins, or  a  rubber  bib.  The  latter  is  especially  serviceable,  and 
should  always  be  at  hand  for  immediate  use  in  an  emergency,  even 
where  it  is  not  deemed  necessary  to  apply  it  at  the  outset  of  the 
operation.  The  saliva  ejector  in  many  instances  seems  to  discom- 
mode the  operator,  and  also  to  prove  with  some  patients  more  of 
an  annoyance  than  a  relief,  though  with  others  it  is  a  very  accept- 
able adjunct.  The  peculiar  preferences  of  patients  must  be 
stiidif'd  in  this  as  in  other  matters. 


48 


PRIiSrCIPLES    AND    PBACTICE    OF    FILLING    TEETH. 


Where  the  ejector  cannot  be  used  the  chief  reliance  should  be 
the  rubber  bib,  because  of  the  inadequate  protection  afforded  by 
napkins  from  the  tendency  of  the  saliva  to  soak  through  and  reach 
the  clothing.  It  need  not  be  intimated  that  the  bib  must  be  kept 
scrupulously  clean  at  all  times,  and  thoroughly  dried  after  wash- 
ing before  being  used  on  another  patient. 

A  very  agreeable  accessory  to  the  use  of  the  dam  is  a  form  of 
napkin,  Fig.  17,  suggested  by  Dr.  J.  W.  Wassail,  to  be  placed 


between  the  dam  and  the  chin.  The  size  of  this  napkin  is  about 
nine  inches  square,  and  the  greatest  depth  of  the  curvature  about 
three  inches  from  the  upper  margin.  Most  patients  are  apprecia- 
tive of  this  attempt  to  keep  the  dam  away  from  the  face,  and  it  is 
especially  useful  in  cases  where  the  contact  of  the  dam  has  a  ten- 
dency to  induce  nausea.  The  curvature  in  the  pattern  fits  ap- 
proximately the  outline  of  the  mouth,  and  the  two  ends  may  be 
tucked  up  imder  the  dam-holder,  and  thus  be  held  in  position  and 
protect  the  cheek.  In  every  case  where  this  napkin  is  not  used  a 
smaller  napkin  should  be  folded  and  placed  between  the  holder 


EXCLUSIO:^"    OF    MOISTURE    DURING    OPERATIONS.  49 

and  the  face  on  either  side,  to  render  the  patient  comfortable  and 
prevent  the  imprint  of  the  holder  being  made  in  the  cheek.  A 
close  observance  of  these  minor  details,  as  they  affect  the  comfort 
of  the  patient,  will  do  much  toward  removing  the  prevalent  dread 
of  dental  operations,  and  no  operator  can  afford  to  neglect  them, 
even  from  the  point  of  view  of  his  own  personal  advantage. 

With  individuals  who  are  inclined  to  be  nauseated  by  the  rub- 
ber dam,  the  difficulty  may  often  be  overcome  by  diverting  atten- 
tion from  the  dam  in  the  following  manner:  Before  applying  the 
rubber  have  everything  in  readiness  to  proceed  at  once  with  the 
operation,  and  the  moment  the  dam  is  in  place  go  vigorously  at 
work  upon  the  tooth  with  something  of  a  hammer-and-tongs 
method;  not  necessarily  inflicting  undue  pain,  but  using  sufiicient 
force  with  the  instrument  to  divert  the  patient's  attention  from  the 
dam  to  the  tooth.  Continue  this  rapidity  of  action  for  some 
minutes,  ignoring  all  attempts  at  protest,  and  directing  every 
energy  upon  the  operation  with  a  quick  succession  of  movements 
and  a  more  or  less  noisy  rattling  of  instruments.  This,  if  pursued 
for  a  time,  will  usually  result  in  the  nausea  passing  away  and  the 
patient  quieting  down,  but  the  operation  must  be  carried  along  to 
completion  without  any  interruptions.  If  the  patient  be  left  for  a 
moment,  even  after  the  nausea  seems  to  have  passed,  the  sensation 
will  return  instantly  when  the  mind  is  allowed  to  dwell  upon  it. 
This  is  why  the  operator  must  seemingly  ignore  the  symptoms  of 
nausea  on  the  first  application  of  the  dam,  and  proceed  with  the 
work  irrespective  of  it.  If  he  quietly  waits  for  the  symptoms  to 
pass  away  they  will  never  pass,  but  grow  progressively  worse  till 
the  dam  must  be  removed.  This  is  only  one  of  many  cases  in 
dental  practice  where  a  bold,  rapid,  and  vigorous  policy  is  the  sole 
line  of  procedure  capable  of  successfully  meeting  the  emergency. 

Kinds  of  Rubber  Dam. 

The  weight  of  the  dam  is  largely  a  matter  of  individual  prefer- 
ence, some  operators  preferring  a  light  dam,  and  others  a  heavy 
one.  The  advantages  of  the  light,  or  thin,  dam  consist  in  its  more 
ready  passage  between  the  teeth,  and  its  consequent  greater  ease  of 

4 


50  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

application;  but  this  is  offset  by  tbe  fact  tbat  it  will  not  ordinarily 
remain  in  place  without  ligating,  and  it  is  too  readily  caught  up 
by  revolving  appliances,  such  as  disks  or  burs.  The  slightest  con- 
tact of  a  rotary  instrument  with  a  piece  of  thin  dam  will  cause  it 
to  be  wound  up  in  the  dam  so  as  to  tear  the  dam  or  puncture  it. 
On  the  other  hand,  very  heavy  dam,  while  ordinarily  more  diffi- 
cult to  apply,  will  to  a  greater  degree  admit  of  the  revolving 
instrument  playing  over  its  surface  without  being  wound  up  or 
injured.  It  will  also  remain  more  securely  placed  on  the  teeth, 
and  seldom  requires  ligatures  to  hold  it.  But  with  some  teeth  the 
contact  of  the  proximating  surfaces  is  such  that  it  becomes  some- 
thing of  a  problem  to  force  thick  dam  between  them,  and  in  gen- 
eral practice  it  would  seem  best  to  employ  a  medium  weight  of 
dam. 

As  to  the  relative  advantages  of  the  twilled  dam  and  the  smooth 
dam,  the  operator  has  his  choice  between  a  dam  which  remains 
well  in  place  when  once  adjusted,  but  which  annoyingly  catches 
on  every  instrument  or  appliance  coming  in  contact  with  it,  and 
one  which  may  not  be  quite  so  tenacious  to  the  tooth,  but  which 
admits  of  reasonable  usage  without  annoyance.  The  twilled  dam 
seems  to  have  an  especial  propensity  for  being  caught  up  by  every 
movement  of  an  instrument  against  it,  and,  while  there  are  some 
operators  who  use  it  successfully  and  with  evident  satisfaction,  it 
will  prove  too  troublesome  for  general  recommendation. 

Size  of  Dam. 

The  size  varies  according  to  the  particular  case  in  hand,  and  the 
location  in  the  mouth.  Tor  the  molars  it  should  be  about  seven 
inches  square,  and  ranging  from  this  down  to  six  inches  for  the 
incisors.  Some  operators  prefer  the  dam  cut  in  the  form  of  a 
triangle  by  dividing  a  square  piece  in  two  from  one  corner  to 
another,  the  long  base  of  the  triangle  being  placed  uppermost  and 
the  ends  grasped  by  the  dam-holder,  while  the  apex  hangs  down 
over  the  chin.  This  is  an  economical  way  of  cutting  the  dam, 
and  answers  a  good  purpose  in  the  anterior  part  of  the  mouth,  but 
for  posterior  teeth  the  square  form  is  preferable. 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS.  51 

Punching  the  Holes. 

The  various  forms  of  rubber-dam  punches  may  be  used  for 
making  the  holes,  but  in  case  a  punch  is  not  available  a  very  simple 
and  very  effective  method  is  as  follows:  Take  a  round  instru- 
ment handle  about  four  millimeters  in  diameter,  slightly  oval- 
faced  on  its  end,  and  perfectly  smooth.  Over  this  stretch  the 
dam,  with  some  tension  at  the  point  where  the  hole  is  desired,  and 
with  a  sharp  knife  nick  the  dam  against  the  side  of  the  handle  a 
short  distance  from  the  end.  This  will  invariably  cut  out  a  per- 
fectly round  piece  of  rubber  and  leave  a  hole  as  true  and  clean  in 
outline  as  is  possible  with  the  sharpest  punch.  The  size  of  the 
hole  may  be  gauged  accurately  by  the  distance  from  the  end  of 
the  instrument  at  which  the  cut  is  made.  If  it  is  near  the  end,  the 
hole  will  be  small ;  if  farther  away,  it  will  be  correspondingly  large. 
In  this  way  it  is  possible  to  vary  the  size  of  the  hole  from  the 
smallest  perceptible  puncture  to  a  hole  the  size  of  a  lead  pencil, 
and  still  have  a  clean-cut  outline. 

The  sizes  required  for  the  different  teeth  will  vary  from  about 
three  millimeters  in  diameter  down  to  one  millimeter,  and  a  little 
practice  will  enable  the  operator  to  cut  the  holes  precisely  as 
desired.  The  width  of  rubber  between  the  holes  must  vary  ac- 
cording to  the  width  of  the  interproximal  spaces  and  the  condi- 
tion of  the  gum-septum  occupying  them.  If  the  teeth  are  long- 
crowned,  with  the  contact  point  near  the  occlusal  surface  and  the 
interproximal  space  large  and  imperfectly  filled  with  gum-tissue, 
the  width  of  dam  between  the  holes  must  be  great;  while  if  the 
teeth  are  short,  with  small  interproximal  spaces  and  the  gum 
coming  up  to  the  contact  point,  there  is  little  room  for  the  dam 
between  the  teeth,  and  it  must  be  correspondingly  narrow.  But 
it  should  never  be  made  so  narrow  that  it  fails  to  adequately  cover 
thci  gum-soptum  and  shut  out  moisture.  If  too  narrow,  it  will, 
when  stretched  between  the  teeth,  pass  down  to  one  side  of  the 
gum-septum  and  pinch  it  against  the  proximal  surface  of  the 
tooth,  leaving  part  of  the  gum  exposed  to  view,  instead  of  having 
it  wholly  covered.     The  width  of  dam  between  the  holes  should 


52  pei:n-ciples  and  practice  of  filling  teeth. 

vary  from  two  to  four  millimeters  in  medium-weiglit  rubber, — tbe 
lighter  the  rubber,  the  greater  the  width  necessary.  This  has  no 
relation  to  cases  of  unusual  spaces  between  teeth  where  the 
proximal  surfaces  are  not  in  contact,  and  where  the  width  of  dam 
must  be  governed  by  the  extent  of  separation. 

Rubber-Dam  Clamps. 

The  use  of  clamps  foil  the  purpose  of  holding  rubber  dam  in 
place  upon  the  teeth  has  been  much  misunderstood  and  greatly 
abused.  Clamps,  if  properly  selected  and  carefully  adjusted,  are 
capable  of  a  wide  range  of  usefulness,  but  if  employed  without  a 
knowledge  of  their  limitations  and  in  direct  violation  of-  the  neces- 
sary care  and  skill,  as  they  frequently  seem  to  be,  they  are  calcu- 
lated to  work  irreparable  injury  to  the  teeth  and  surrounding  parts^ 
and  involve  the  patient  in  much  needless  suffering. 

The  principal  faults  in  the  manipulation  of  clamps  consist  in  a 
failure  to  select  the  suitable  form  of  clamp  for  the  case  in  hand, 
and  a  lack  of  care  in  its  proper  adjustment.  A  clamp  that  does 
not  approximately  fit  the  tooth  cannot  be  expected  to  effectively 
remain  in  position  vdthout  undue  impingement  at  certain  points, 
which  results  in  injury  and  discomfort.  An  operator  should  have 
a  sufficient  number  of  forms  to  meet  the  varying  cases  presented 
in  the  mouth,  and  to  this  end  should  make  a  careful  study  of  the 
different  teeth  with  especial  relation  to  the  shapes  of  the  crowns, 
and  necks,  so  as  to  be  able  to  make  his  selection  of  clamps  with 
intelligence.  In  the  adjustment  of  a  clamp  harm  may  be  done 
in  two  ways:  the  clamp  may  be  too  small  for  the  tooth  and  pinch 
it  so  severely  at  the  neck  as  to  injure  the  tooth,  especially  in  a 
long  operation  where  the  slight  movement  of  the  clamp  resulting 
from  the  pressure  of  the  rubber  dam  against  the  bow  may  cause 
the  sharp  beaks  to  grind  against  the  enamel  so  as  to  indent  it;  or 
the  clamp  may  work  so  far  rootwise  on  the  tooth  as  to  cause  im- 
pingement on  the  gum  and  set  up  serious  inflammation.  Even  if 
this  injury  is  not  always  permanent,  it  is  sufficiently  distressing  to 
the  patient  to  account  for  future  distrust  and  apprehension  when- 
ever the  clamp  is  employed. 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS.  53 

The  rubber  dam  itself  is  sufficiently  objectionable  to  the  average 
individual  without  adding  to  the  dread  by  painful  methods  of 
application,  and,  while  it  is  not  always  possible  to  maintain  the 
dam  in  place  without  some  slight  discomfort,  there  is  no  excuse 
for  inflicting  the  serious  injury  in  its  use  that  is  too  often  done  by 
careless  operators.     The  clamp  may  be  used  in  the  large  majority 
of  cases  without  perceptible  pain  or  other  ill  effects,  if  properly 
selected  and  sldllfully  applied.     The  two  classes  of  teeth  most 
difficult  to  manage  in  this  regard  are  those  of  the  extreme  bell- 
cro^^^led  variety,  where  the  crowns  are  exceedingly  long  with 
broad  occlusal  surfaces,  and  the  short  conical  teeth  appearing  very 
little  al)0ve  the  gum.     In  the  former  case  the  contact  points  on 
the  proximal  surfaces  are  near  the  occlusal  surface,  and  the  inter- 
proximal spaces  are  large  and  long.     The  tooth  at  the  gingival 
line  is  much  narrower  in  circumference  than  at  the  occlusal  sur- 
face, and  the  buccal  and  lingual  surfaces  accordingly  present  an 
incline  toward  the  gum.     The  ordinary  clamp  applied  to  a  molar 
or  bicuspid  of  this  type  has  a  tendency  to  slide  along  this  incline 
and  gradually  impinge  seriously  upon  the  gum.     Every  movement 
of  the  rubber  dam  against  the  bow  of  the  clamp  tends  to  force  it 
still  farther  along  the  incline,  till  it  becomes  excruciating  to  the 
sensitive  gum-tissue.     To  obviate  this  difficulty  clamps  have  been 
devised  with  stays  on  the  bows  to  rest  on  the  occlusal  surface  of 
the  tooth,  with  the  idea  of  preventing  the  clamp  from  slipping 
too  far  rootwise,  but  in  many  cases  these  stays  do  not  prevent  the 
clamp  from  tipping  forward  and  gouging  the  anterior  point  of  the 
beak  in  the  gum,  and  in  other  cases  the  stays  are  in  the  way  of  the 
operation.     The  better  method  where  these  extreme  bell-crowned 
teeth  are  encountered  is  to  dispense  with  the  clamp  altogether  and 
secure  the  dam  by  some  other  means. 

The  other  form  of  tooth,  in  which  the  crown  is  short  and  the 
tooth  much  larger  in  circumference  at  the  free  margin  of  the  gum 
than  at  the  occlusal  surface,  presents  difficulties  of  a  vastly  dif- 
ferent character.  In  this  case  the  incline  is  from  the  gum  toward 
the  occlusal  surface,  and  the  chief  problem  presented  is  to  main- 
tain a  clamp  in  position  at  all.     The  inevitable  tendency  is  to  dis- 


54  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

lodge  the  clamp  bj  the  slightest  movement,  and  unless  the  clamp 
is  made  secure  in  the  beginning  of  the  operation  an  intricate  piece 
of  work  may  be  jeopardized,  and  even  ruined,  by  dislodgment  of 
the  clamp  when  the  operation  is  only  partially  completed.  In  this 
instance  there  is  little  danger  of  injuring  the  tooth  or  the  gum 
with  the  clamp.  It  may  cause  temporary  discomfort,  but  seldom 
permanent  injury.  The  gum  covers  the  enamel  to  such  an  extent 
that  the  enamel  is  thick  at  the  point  where  the  clamp  rests,  and  as 
for  the  gum,  it  will  usually  be  found  lapping  over  the  surface  of 
the  tooth  to  a  considerable  distance  from  the  point  where  it  is 
attached  to  the  root.  This  flap  of  overlying  gum  may  safely  be 
forced  back  by  the  clamp  at  several  points  sufficiently  to  admit  a 
grip  of  the  beaks  without  permanent  injury,  provided  it  is  not 
pinched  by  the  beaks  or  severely  lacerated.  If  necessary,  a  local 
anesthetic  may  be  used  on  the  gum  before  applying  the  clamp, 
and  after  the  operation  an  anodyne  antiseptic  should  be  applied 
and  the  gum  gently  kneaded  against  the  buccal  and  lingual  sur- 
faces with  the  finger. 

Tor  extremely  difficult  cases  of  this  character,  such  as  are  some- 
times encountered  in  stunted  third  molars,  a  specially  devised 
clamp  is  indicated,  to  be  referred  to  subsequently. 

With  the  exception  of  these  two  classes  of  teeth,  and  the  peculiar 
difficulties  experienced  in  the  management  of  labial,  lingual,  or 
buccal  cavities,  the  ordinary  use  of  clamps,  if  properly  adjusted, 
ought  not  to  be  a  serious  dread  to  the  patient. 

KINDS  OF  CLAMPS. 

Clamps  for  Molars  and  Bicuspids. 

In  the  application  of  the  rubber  dam  to  molars  and  bicuspids, 
the  chief  problem  in  the  past  has  related  to  the  difficulty  of  carry- 
ing the  rubber  back  over  the  teeth  and  holding  it  there  while  the 
clamp  was  being  adjusted.  To  carry  the  dam  to  place  with  the 
fingers,  particularly  over  teeth  far  back  in  the  mouth,  was  exceed- 
ingly awkward,  and  in  some  cases  almost  impossible  without  dis- 
tressing the  patient.     To  overcome  this,  operators  were  in  the 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS. 


55 


habit  of  passing  the  beaks  of  the  clamp  through  the  hole  in  the 
dam  and  carrying  the  clamp  and  rubber  to  place  at  once,  after- 
ward lifting  the  rubber  over  the  beaks  and  passing  it  between  them 
and  the  gum.  The  drawback  to  this,  with  beaks  of  the  ordinary 
form,  was  the  fact  that  the  rubber  stretched  across  the  opening 
between  the  beaks  and  obscured  the  tooth  so  that  it  was  difficult 
to  see  where  the  clamp  was  being  placed.  A  new  form  of  clamp 
was  devised  to  obviate  this,  known  as  the  Ivory  clamp,  in  which 
the  beaks  are  carried  out  buccally  and  lingually  and  then  turned 
down  into  a  flange,  over  which  the  rubber  may  be  hung,  leaving 
the  space  between  the  beaks  open  for  perfect  vision.  With  this 
form  of  clamp  the  application  of  the  rubber  dam  is  a  very  simple 
matter,  as  will  be  detailed  later. 

Another  advantage  of  this  clamp  is  the  projecting  forward  of 
an  extension  from  each  beak  to  hold  the  rubber  out  of  the  way 
during  an  operation.  In  this  connection  it  may  be  stated  that 
one  of  the  chief  offices  of  the  clamp,  aside  from  its  service  in  main- 
taining the  rubber  on  the  tooth,  is  to  keep  it  away  from  the  region 
of  the  cavity,  so  that  it  shall  not  constantly  be  in  the  operator's 
light  and  be  caught  up  with  instruments  and  displaced.  The  bows 
of  the  clamp  accomplish  this  distally,  and  the  projections  on  the 
beaks  of  the  Ivory  clamp  do  it  buccally  and  lingually.  Figs.  18 
and  19  illustrate  the  Ivory  clamp  with  the  flanges  referred  to  and 
the  maimer  of  hanging  the  rul)ber  over  them.  Fig.  20  is  a  special 
form  of  beak  which  Avill  be  found  very  serviceable  for  those  diffi- 
cult cases  previously  referred  to, — the  short  conical  teeth  whose 
buccal  and  lingual  surfaces  incline  sharply  toward  each  other  as 
thev  pass  from  the  gum-margin  to  the  occlusal  surface,  so  as  to 
lead  to  the  displacement  of  an  ordinary  clamp.  As  will  be  seen, 
the  extremities  of  the  beaks  are  deflected  in  such  a  way  as  to  dip 
under  the  free  margin  of  the  gum  and  grasp  the  tooth  well  root- 
wise.  This  clamp  would  be  an  exceedingly  cruel  device  to  use 
in  ordinary  operating,  but  for  these  especially  trying  cases  it  will 
securely  maintain  the  rubber  in  place  when  no  other  form  of 
clamp  is  effective,  and  if  used  Avith  discriminating  care  it  need  not 
be  productive  of  any  serious  injury  or  discomfort  to  the  patient. 


66 


PErSrCIPLES    AKD    PEACTICE    OF    FILLIIN^G    TEETH. 


The  operator  slioiild  have  a  large  assortment  of  special  forms  of 
clamps  to  m.eet  all  the  special  cases,  but  for  ordinary  use  a  few  of 
the  standard  forms  of  molar  and  bicuspid  clamps  will  do  the  major 
part  of  the  work  in  the  routine  of  office  practice. 


Fig.  18. 


Fig.  19. 


Fig  20. 


Cervical  Clamps  for  Buccal,  Labial,  or  Ling-ual  Cavities. 

With  the  large  range  of  service  demanded  of  a  cervical  clamp 
and  the  intricate  positions  it  is  sometimes  called  upon  to  reach,  it 
could  scarcely  be  expected  that  any  one  form  of  clamp  would 
advantageously  cover  all  cases.  Much  improvement  has  been 
made  in  recent  years  in  the  development  of  the  cervical  clamp, 
and  .some  of  the  more  modem  forms  would  seem  to  be  as  nearly 
universal  as  ingenuity  can  make  them;  but  for  the  average  practi- 
tioner it  will  be  found  best  to  have  several  varieties  to  meet  all  of 
the  emergencies  that  may  present.  Some  operators  seem  to  have 
a  special  aptitude  for  one  particular  kind  of  clamp,  and  are  ap- 
parently able  to  accomplish  more  with  it  than  with  any  other;  but 
for  mo.st  men  it  will  be  necessary  to  have  at  least  three  or  four 
forms  to  secure  the  best  results. 

The  forms  here  illustrated  are  not  intended  to  include  all  of  the 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS. 


serviceable  clamps  in  the  market,  but  with  these  in  his  case  the 
operator  will  be  reasonably  well  equipped  to  meet  most  cases  apply- 
ing to  him  for  treatment.  Fig.  21  is  the  Keefe  clamp,  a  feature 
of  which  is  the  triple  bearing  on  the  tooth  afforded  by  the  three 
jaws  or  beaks.  This  tends  to  hold  the  clamp  securely  in  place  and 
prevent  rocking  when  screwed  down  snug  with  the  set-screw.  To 
provide  for  different  lengths  and  forms  of  teeth  and  the  various 
positions  of  cavities  two  of  the  beaks  are  made  adjustable,  by  which 
means  the  clamp  has  a  wide  longitudinal  range  on  the  tooth,  so 
as  to  be  carried  well  rootwise  in  cases  of  extensive  caries.  In 
using  this  clamp  it  should  first  be  carefully  adjusted  to  the  tooth 

Fig.  21. 


Fig.  22. 


Fig.  23. 


before  the  rultber  is  in  place,  so  that  the  operator  may  clearly  see 
all  of  the  bearings  and  set  the  movable  beaks  in  the  correct  posi- 
tion. It  may  then  be  taken  from  the  tooth,  the  rubber  adjusted, 
and  the  clamp  retnrned  to  place,  after  which  the  set-screw  may  be 
turned  down  tight  to  hold  the  clamp  firm. 

Fig.  22  represents  the  Dunn  clamp  jSTo.  2,  whicli  is  intended  to 
be  as  widely  universal  as  po.ssible.  The  bows  are  strong  and  rigid, 
so  as  to  gain  security  of  retention  when  the  set-screw  is  tightened. 
In  cases  of  extensive  decay  rootwise  the  beak  may  be  carried 
beyond  the  cavity  by  ])lacing  a  tliick  pad  of  bibulous  paper 
between  the  opposite  l^eak  and  tlie  gum,  against  which  the  clamp 
may  be  tightened  without  injury  to  the  tissues.  This  pad  will 
enable  the  operator  to  give  the  clamp  a  wide  range  of  position,  and 


58  PKINCIPLES    AND    PRACTICE    OF    FILLING-    TEETH. 

should  be  employed  in  most  cases  where  the  clamp  is  used.  The 
clamp  should  be  loosely  placed  upon  the  tooth  with  the  pad  under 
the  lingual  beak,  and  then  the  labial  beak  gently  forced  to  posi- 
tion and  the  clamp  tightened  with  the  set-screw.  In  case  the  arch 
of  the  teeth  in  the  cuspid  region  interferes  with  the  bow,  the  clamp 
may  be  reversed  and  used  with  the  bows  looking  in  the  opposite 
direction. 

Fig.  23  is  the  Libby  clamp,  made  in  a  right  and  left.  The  dis- 
tinctive feature  of  this  clamp  is  the  hinged  beak  or  pivoted  shoe 
on  the  lingual  extremity,  which  enables  the  clamp  to  readily  seek 
a  bearing  and  remain  fixed  in  any  position  where  it  is  placed.  This 
clamp  should  be  carried  to  position  with  the  Brewer  clamp  forceps, 
Fig.  24;  and  when  once  properly  adjusted  it  maintains  its  place 
very  satisfactorily,  on  account  of  the  broad  bearing  provided  by 
the  hinged  apparatus  on  its  lingual  aspect.  The  fact  that  the 
extremity  of  this  usually  rests  against  the  gum  renders  it  desirable 
to  protect  the  gum  from  too  great  pressure  by  slipping  a  short  sec- 
tion of  half -inch  rubber  tubing  over  it  before  applying  the  clamp. 
With  this  rubber  pad  properly  adjusted  there  is  never  any  com- 
plaint from  the  patient,  and  it  does  not  seem  to  interfere  with  the 
security  of  the  clamp. 

A  careful  study  of  the  proper  method  of  using  the  three  kinds 
of  clamps  here  illustrated  will  enable  the  operator  to  successfully 
meet  the  most  difiicult  cases  which  apply  to  him  for  treatment,  and 
will  render  the  average  cases  very  easy  of  control.  In  some  in- 
stances the  clamp  will  need  to  be  steadied  by  the  fingers  of  the 
operator  to  make  certain  that  there  shall  be  no  movement,  but  the 
usual  length  of  time  necessary  to  complete  an  operation  of  this 
kind  ought  not  to  be  sufiiciently  long  to  make  this  especially 
irksome. 

Ligatures. 

In  operating  on  proximal  cavities  in  the  anterior  teeth  where 
clamps  are  not  indicated,  or  in  cases  of  bell-crowned  molars  and 
bicuspids  where  the  clamp  would  prove  too  cruel,  ligatures  may 
be  used  for  the  retention  of  the  dam  to  good  effect.     The  most 


EXCLUSION    OF    MOISTUEE    DURING    OPERATIONS. 
Fig.  24. 


59 


60  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

serviceable  kind  of  ligature  is  waxed  floss  silk,  on  account  of  its 
great  strength  in  relation  to  its  bulk,  thereby  admitting  a  suffi- 
ciently strong  ligature  to  be  readily  forced  between  the  teeth. 

In  cases  where  the  dam  has  a  tendency  to  be  dragged  over  the 
ligature  and  become  displaced,  leaving  the  ligature  on  the  tooth, 
the  difficulty  may  be  overcome,  by  the  use  of  small  glass  beads 
strung  on  the  ligature  and  distributed  at  various  points  around  the 
tooth.  On  a  molar,  for  instance,  where  the  tendency  would  be 
greatest  for  the  dam  to  slip,  a  bead  may  be  placed  respectively  at 
the  disto-buccal,  the  disto-lingual,  the  mesio-buccal,  and  the  mesio- 
lingual  angles  of  the  tooth,  and  these  beads  will  present  sufficient 
bulk  to  resist  the  displacement  of  the  dam.     In  lieu  of  beads  Dr. 

Fig.  25. 


E.  K.  Wedelstaedt  has  suggested  the  tying  of  a  small  roll  of  cot- 
ton in  the  ligature,  and  thus  creating  bulk.  The  manner  of 
adjusting  the  ligature  is  to  force  it  between  the  teeth  on  the  distal 
surface  of  the  tooth  to  be  ligated,  pass  it  around  the  lingual  sur- 
face, and  out  buccally  or  labially,  as  the  case  may  be,  between  the 
mesial  surface  of  this  tooth  and  the  distal  surface  of  the  one  next 
in  line.  The  two  ends  of  the  ligature  now  extend  out  so  the 
operator  may  readily  grasp  them,  but  the  portion  embracing  the 
tooth  is  usually  not  far  enough  rootwise.  Before  attempting  to 
force  the  ligature  to  place  the  first  loop  of  a  surgeon's  knot  should 
be  formed,  like  Fig.  25,  by  passing  one  end  of  the  ligature  twice 
around  the  other,  instead  of  once.  This  kind  of  a  knot  will  hold 
firm  when  drawn  tight  against  the  tooth  to  a  greater  degree  than 
where  the  ordinary  knot  is  used,  and  will  thus  admit  of  the  second 
loop  of  the  knot  being  tied  without  the  ligature  loosening.     Before 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS.  61 

drawing  the  first  loop  tight  the  ligature  should  be  forced  as  far 
rootwise  on  the  lingual  surface  as  is  desired  with  an  instrument, 
and  while  being  held  there  the  strands  of  the  ligature  may  be  car- 
ried well  into  the  interproximal  spaces  by  gentle  force  on  the  free 
ends  exerted  in  an  oblique  direction  buccally  (or  labially)  and 
slightly  rootwise.  When  the  ligature  on  the  mesial  and  distal 
sides  of  the  tooth  has  glided  under  the  free  margin  of  the  gum  and 
carried  the  dam  with  it  the  first  loop  of  the  knot  may  be  drawn 
tight,  which  will  securely  fix  the  ligature  and  dam  in  place  till  the 
second  loop  of  the  knot  is  tied..  This  second  loop  need  not  be 
double-twisted,  as  the  fii'st.  When  the  ligature  is  thus  tied  the 
free  ends  may  be  cut  near  the  knot,  preferably  with  a  small 
curved  pair  of  scissors  like  manicure  scissors. 

This  forcing  of  the  ligature  to  place  is  to  some  patients  painful, 
while  others  do  not  seem  to  mind  it  in  the  least,  the  difference  be- 
ing due  to  the  natural  sensitiveness  of  certain  patients  more  than 
others,  and  also  to  the  fact  that  in  some  conditions  of  the  gums 
there  is  an  undue  tenderness  to  pressure  even  when  the  individual 
is  not  otherwise  nervous.  The  fact  that  the  ligature  in  any  in- 
stance may  give  pain  should  influence  the  operator  to  dispense  with 
it  whenever  possible,  and  in  actual  work  in  the  mouth  this  may  be 
done  to  a  very  large  degree.  If  the  dam  is  of  the  proper  weight 
and  is  skillfully  adjusted  it  is  the  exception,  rather  than  the  rule, 
for  a  ligature  to  be  required.  The  chief  problem  of  retaining 
the  dam  in  place  without  a  ligature  consists  in  so  applying  the 
dam  that  the  edges  of  the  holes  are  curled  up  under  the  free  mar- 
gin of  the  gum  and  look  rootwise  instead  of  crownwise.  If  this 
can  be  accomplished,  the  rubber  will  ordinarily  remain  in  place 
and  prevent  leakage  without  a  ligature.  To  do  this  the  dam 
should  be  stretched  rootwise  by  placing  the  ends  of  the  fingers  over 
the  dam  on  the  buccal  (or  labial)  and  lingual  sides  of  the  hole,  and 
forcing  it  against  the  gum  and  toward  the  root.  If,  on  being 
released,  the  dam  does  not  curl  uj)  to  position  as  desired,  it  may 
often  be  tucked  to  place  with  a  smooth  blunt-edged  instrument 
like  an  amalgam  spatula  by  stretching  the  dam  rootwise  and  sweep- 
ing the  instrument  obliquely  along  under  the  edge  of  the  dam  a? 


62  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

it  is  being  released.  Where  this  is  not  effective  the  dam  may 
readily  be  curled  under  by  ligating  the  tooth,  a  procedure  which 
will  invariably  result  in  turning  the  edges  of  the  dam  so  that  they 
extend  rootwise.  If  it  is  a  case  where  there  is  objection  to  the 
ligature,  or  where  the  ligature  does  not  seem  necessary  for  retain- 
ing the  dam,  it  may  be  immediately  removed  after  the  rubber  has 
been  carried  to  place. 

Occasionally  it  is  necessary  to  ligate  only  one  or  two  teeth  in  a 
given  series  embraced  by  the  dam.  The  tooth  to  be  operated  on 
will  usually  require  ligating  to  secure  the  maintenance  of  the 
rubber  in  its  proper  place  and  prevent  leakage,  unless  a  clamp  is 
being  used.  If  the  cavity  is  a  proximal  one  it  is  often  neces- 
sary to  ligate  the  tooth  next  in  line,  so  that  the  strip  of  dam  in  the 
interproximal  space  will  be  held  well  out  of  the  way  and  any 
possible  oozing  of  moisture  under  the  margin  of  the  dam  avoided. 
The  last  tooth  embraced  by  the  dam  and  farthest  from  operation 
may  also  require  ligating  to  prevent  the  rubber  from  being 
dragged  away  by  the  action  of  the  lips  or  the  tongue,  though  it 
will  frequently  be  found  that  ligating  can  be  dispensed  with  in 
such  a  case  by  merely  drawing  between  the  proximal  surface 
of  this  tooth  and  the  rubber  as  it  hangs  up  over  the  tooth  not 
embraced  by  it  a  single  strand  of  the  ligature  and  cutting  it  off, 
allowing  a  piece  of  the  strand  about  five  or  six  millimeters  in 
length  to  hang  as  a  wedge  between  the  dam  and  the  tooth  last 
embraced.  In  case  there  is  too  much  space  between  the  teeth  to 
render  the  strand  effective,  a  piece  of  rubber  may  be  substituted 
for  it  by  using  an  ordinary  elastic  band  of  suitable  size,  stretching 
this  to  place,  and  cutting  it  the  proper  length. 

In  cases  where  there  is  appreciable  recession  of  the  gums,  leav- 
ing the  interproximal  spaces  somewhat  open  and  admitting  a  cer- 
tain amount  of  movement  to  the  dam  between  the  teeth,  the  ten- 
dency is  often  great  for  the  dam  to  leak  unless  it  is  held  against  the 
gum  and  kept  from  movement.  To  ligate  all  of  the  teeth  is 
usually  more  or  less  distressing  to  the  patient,  besides  consuming 
time.  A  much  less  painful  and  a  more  rapid  method  is  to  pack  a 
bit  of  cotton  in  each  interproximal  space  between  the  contact 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS.  63 

points  of  the  teetb  and  the  rubber,  forcing  the  cotton  well  np 
toward  the  contact  points  so  that  it  will  remain  wedged 
to  place.     This  will  usually  be  quite  effective  in  hold-       ^    '• 
iug  the  rubber  to  position  against  the  gum,  and,  if  done      ^^  / 
with  care,  need  not  give  the  patient  the  slightest  dis- 
comfort.    The  operator  should  never  forget  to  remove 
these  little  cotton  plugs  before  attempting  to  take  off 
the  dam,  otherwise  he  is  likely  to  give  a  rather  uncom- 
fortable pull  to  the  dam  without  removing  it. 

In  every  instance  where  there  is  the  slightest  doubt 
about  the  dam  passing  readily  between  the  teeth,  a  liga- 
ture or  strip  of  rubber  should  first  be  carried  between  all 
of  the  teeth  to  be  embraced  by  the  dam,  to  make  certain 
that  the  spaces  are  clear  and  free  from  rough  or  sharp 
edges  calculated  to  cut  the  dam.  Sometimes  bits  of  cal- 
culus are  found  on  the  proximal  surfaces,  and  these 
should  invariably  be  removed  before  the  dam  is  ap- 
plied. In  other  cases  incipient  caries  may  have  be- 
gun near  the  contact  point  on  teeth  other  than  the 
one  being  operated  on,  and  the  sharp  margin  of  the 
cavity  may  cut  the  ligature  or  rubber.  To  obviate  this 
a  thin  broad  instrument  like  the  gum-depressor,  Fig.  26, 
should  be  forced  between  the  teeth  with  a  see-sawing 
motion,  so  as  to  smooth  the  rough  or  jagged  edges  of 
enamel  in  advance  of  the  application  of  the  dam.  This 
instrument  may  be  readily  passed  between  the  contact 
points  of  the  teeth,  especially  if  the  edge  has  been 
ground  quite  thin,  and  after  its  free  passage  the  dam 
may  be  applied  with  safety. 

When  the  teeth  are  thus  prepared  for  the  reception 
of  the  dam,  a  general  survey  of  the  situation  should  be 
made  to  determine  the  required  location  of  the  holes. 
For  the  lower  molar  teeth  the  last  hole  back  should  be 
aVjout  three  inches  from  the  upper  edge  of  the  dam,  and 
about  two  and  one-half  or  three  inches  from  the  edge  on 
the  side  of  the  operation,  though  this  may  vary  some- 


64  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

what  according  to  the  shape  of  the  jaws  and  lips  of  the  patient. 
For  lower  bicuspids  the  holes  may  be  somewhat  nearer  either  edge, 
but  in  no  instance  should  they  be  near  enough  to  prevent  the  dam 
from  properly  covering  the  upper  lip  and  angles  of  the  mouth.  For 
the  upper  molars  or  bicuspids  the  last  hole  back  need  not  be  more 
than  two  inches  from  either  side.;  Following  this  point  forward, 
the  holes  should  be  cut  so  as  to  correspond  with  the  curve  of  the 
arch,  and  in  every  instance  a  sufficient  number  of  teeth  should  be 
included  in  the  dam  to  properly  expose  the  operation  to  view  and 
keep  the  dam  well  out  of  the  operator's  way.  It  is  too  frequently 
the  case  that  operators  hamper  themselves  in  their  work  by  includ- 
ing only  one  or  two  teeth  in  the  dam,  thereby  allowing  the  dam 
to  curl  up  about  the  cavity  and  hide  it  from  view,  besides  risking 
the  danger  of  continually  catching  the  dam  in  burs  or  other  revolv- 
ing instruments.  There  may  be  occasional  instances  where,  on 
account  of  the  difficulty  of  applying  the  dam,  it  is  justifiable  to 
limit  as  far  as  possible  the  number  of  teeth  to  be  embraced  by  it, 
but  under  ordinary  conditions  in  operating  upon  the  molars 
or  bicuspids  the  dam  should  be  made  to  include  the  teeth  as  far 
forward  as  the  lateral  or  even  the  central  incisor.  Aside  from  the 
idea  of  having  the  dam  well  out  of  the  way,  there  is  an  anatomical 
reason  for  ending  at  one  of  the  incisors.  To  end  at  the  cuspid 
would  often  afford  the  operator  ample  opportunity  for  work,  but 
the  form  of  this  tooth  is  usually  such  as  to  render  it  unsuited  to  be 
the  last  tooth  embraced  by  the  dam.  It  is  often  so  cone-shaped 
that  the  dam  readily  draws  away  from  it,  while  the  mesial  sur- 
faces of  the  incisors  ordinarily  present  such  an  incline  as  to  prove 
an  excellent  medium  over  which  to  hang  the  last  hole  of  the  dam. 

Manner  of  Applying  the  Dam  in  Different  Locations  in  the  Mouth. 

To  apply  the  dam  to  the  lower  bicuspids  and  molars  the  operator 
should  first  select  a  suitable  clamp  to  fit  the  last  tooth  back  to  be 
included  in  the  dam,  and,  after  hanging  the  dam  over  the  fianges 
of  the  clamp  and  adjusting  the  clamp  forceps,  he  should  grasp 
the  upper  edge  of  the  dam  with  the  thumb  and  fingers  of  the  left 
hand  in  such  a  way  as  to  stretch  the  dam  up  against  the  bow  of 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS.  65 

the  clamp  and  hold  the  edges  well  out  of  the  way  of  perfect  vision 
during  the  application.  Then,  standing  to  the  right  and  slightly 
in  front  of  the  patient,  with  the  chin  raised  sufficiently  to  look 
directly  into  the  mouth,  the  clamp  with  dam  attached  should  be 
carried  to  place  upon  the  tooth.  The  clamp  should  be  adjusted 
with  the  utmost  delicacy  and  gentleness,  so  as  to  inflict  the  least 
possible  discomfort.  In  some  instances  the  first  grip  of  the  clamp 
on  the  tooth  will  cause  a  slight  flinching  on  the  part  of  the  patient, 
but  if  it  is  a  clamp  of  the  proper  form  for  the  case  in  hand  and  is 
carefully  applied  all  appreciable  discomfort  passes  away  in  a 
moment.  Immediately  following  the  placement  of  the  clamp  the 
forceps  should  be  laid  aside  and  a  pair  of^pliers  or  a  thin-bladed 
spatula  should  be  employed  to  lift  the  rubber  free  from  the 
flanges  of  the  clamp,  so  as  to  let  it  snap  around  the  tooth.  The 
dam  thus  fixed,  the  edges  may  be  fastened  back  out  of  the  way, 
with  the  dam-holder  around  the  patient's  head,  when  both  hands 
will  be  free  for  the  further  adjustment  of  the  dam  over  the  remain- 
ing teeth.  With  the  number  of  holes  in  the  dam  already  fixed 
in  his  mind,  the  operator  should  count  back  toward  the  tooth 
embraced  by  the  clamp  to  be  assured  that  he  is  placing  each  hole 
over  the  proper  tooth,  otherwise  he  may  make  the  mistake  of 
leaving  a  hole  in  the  dam  between  the  tooth  embraced  by  the 
clamp  and  the  one  in  front  of  it.  Then,  starting  at  the  tooth  next 
to  the  one  already  exposed  by  the  clamp,  he  should  consecutively 
pass  the  rubber  over  each  tooth  till  all  are  included.  This  should 
be  done  by  forcing  the  edge  of  the  dam  bordering  the  hole  past  the 
contact  points,  and  thus  carrying  the  strip  of  rubber  between  the 
holes  into  the  interproximal  space.  If  at  any  point  the  rubber 
seems  to  stick  and  refuses  to  pass  between  the  teeth  short  of  suflB.- 
cient  stretching  to  risk  the  danger  of  tearing  the  dam,  the  rubber 
should  be  merely  hung  over  this  particular  tooth  while  the  operator 
passes  to  the  others  and  slips  the  dam  over  them.  Then  the 
ligature  may  be  used  to  force  the  dam  past  the  difiicult  spaces,  and 
a  careful  examination  made  to  see  that  there  are  no  points  at  which 
a  leak  may  occur.  In  doing  this  the  distal  surface  of  the  tooth 
embraced  hy  the  clamp  must  not  be  overlooked.     If  the  dam  hangs 

6 


66  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

over  this  tootli  so  as  to  invite  leakage,  the  ligature  should  be  used  to 
carry  the  dam  well  between  this  tooth  and  the  one  back  of  it. 

After  the  proper  adjustment  of  the  dam  the  comfort  of  the 
patient  must  be  looked  to,  as  previously  indicated,  by  the  use  of 
napkins,  cheek  pads,  rubber  bibs,  etc.  If  the  lower  edges  of  the 
dam  exhibit  an  inclination  to  curl  up  in  the  operator's  way,  they 
may  be  fastened  down  by  weights. 

In  applying  the  dam  to  the  upper  bicuspids  and  molars  the  plan 
of  procedure  is  much  the  same  as  for  the  lower  teeth,  except  that 
some  of  the  motions  must  be  reversed,  and  the  position  of  the 
patient  and  operator  slightly  changed.  The  grasp  of  the  clamp 
forceps  is  also  different.  When  adjusting  the  clamp  to  the  lower 
teeth  the  forceps  is  placed  with  the  claws  looking  downward,  and 
the  handles  are  grasped  in  the  palm  of  the  hand  with  the  back  of 
the  hand  upward  and  the  thumb  pressing  against  the  outside  of  the 
handle  nearest  the  operator  close  to  the  hinge,  while  the  fingers 
reach  over  and  clasp  the  handle  farthest  from  the  operator.  (Fig. 
27.) 

Tor  the  upper  teeth  the  claws  of  the  forceps  look  upward  and 
the  back  of  the  operator's  hand  downward.  The  handles  of  the 
forceps  pass  diagonally  across  the  palm  between  the  second  and 
third  fingers  and  out  between  the  thumb  and  index  finger,  so  that 
the  handles  near  the  end  are  grasped  by  the  thumb  and  index 
finger,  and  farther  down  toward  the  hinge  by  the  second  and  third 
fingers.  The  ends  of  the  index  and  second  fingers  clasp  around 
and  over  the  top  of  the  handle  farthest  from  the  operator,  while 
the  thumb  clasps  around  and  over  the  top  of  the  handle  nearest 
him,  and  the  ends  of  all  three  are  turned  so  as  to  look  somewhat  in 
the  direction  of  the  claws.  Thus  the  only  finger  not  touching  the 
forceps  is  the  little  finger,  and  the  principal  grasping  force  is 
exerted  by  the  index  finger  and  the  thumb,  while  the  lifting  force 
in  carrying  the  clamp  to  place  is  exerted  by  the  third  finger  as  the 
handle  lies  across  it.     (Fig.  28.) 

In  adjusting  the  dam  to  the  upper  teeth  the  patient's  head 
should  be  tipped  back  so  as  to  expose  these  teeth  as  perfectly  as 
possible,  and  for  the  right  side  of  the  mouth  the  operator  should 


EXCLUSIOX    OF    MOISTUUE     DURING    OPERATIOXS. 


67 


stand  to  the  right  and  in  front  of  the  patient  with  the  patient's 
head  slightly  tnrned  to  the  right,  so  as  to  present  the  occlusal  sur- 
faces of  the  teeth  directly  toward  the  operator,  the  chin  being 
raised  to  a  convenient  height  for  this  purpose. 

On  the  left  side  of  the  mouth  the  teeth  can  often  be  better  ap- 
proached by  slightly  lowering  the  chair  and  stepping  a  trifle  to  the 

Fin.  27. 


back  of  the  i)atient,  so  as  to  pass  tlie  left  liand  and  arm  over  and 
around  the  patient's  head  to  hold  the  upper  edge  of  the  rubber 
away  while  tlie  right  hand  is  iiiaui})uhvting  the  forceps.  The 
operator  should  study  carefully  the  various  peculiarities  of  form 
and  position  ])rcs('iitc<l  hy  the  difVcrcnt  mouths  and  tooth  of  indi- 
viduals, so  as  thereby  to  avail  himself  of  every  advantage  which 
his  ingenuity  may  suggest.  "J'here  is  always  a  best  and  handiest 
way  of  doing  these  tilings,  but  no  one  way  is  always  the  best  nor 


68 


PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 


the  handiest,  and  to  gain  the  most  satisfactory  results  in  every  case 
the  operator  mnst  be  prepared  to  vary  his  methods,  so  far  at  least 
as  the  minor  details  of  execution  are  concerned. 

For  the  upper  incisors  and  cuspids  the  holes  should  be  punched 
in  the  dam  from  an  inch  and  a  half  to  two  inches  from  the  upper 
edge,  depending  on  the  case.     The  former  distance  will  be  ample 

Fig.  28. 


in  most  instances,  but  for  a  gentleman  patient  with  a  large 
moustache  the  holes  should  be  at  least  two  inches  from  the  edge, 
to  aiford  sufficient  area  of  dam  to  perfectly  cover  the  moustache 
and  hold  it  out  of  the  way.  In  no  case  should  the  dam  be  allowed 
to  pass  over  the  nostrils  and  obstruct  the  patient's  breathing.  For 
the  lower  anterior  teeth  the  holes  should  be  from  three  inches  to 
three  inches  and  a  half  from  the  upper  margin,  so  that  the  mouth 


EXCLUSION    OF    MOISTURE    DUKIXG    OPERATIONS,  69 

mav  be  thrown  well  open  and  still  admit  of  the  dam  extending 
over  the  upper  lip. 

To  adjust  the  ruV)l)er  to  the  upper  anterior  teeth  the  upper  edge 
of  the  dam  should  be  grasped  by  the  left  hand  in  such  a  manner 
that  the  back  of  the  hand  looks  away  from  the  patient's  face,  while 
the  palm  is  turned  toward  the  face  and  the  ends  of  the  fingers 
look  downward  with  the  elbow  raised  over  the  patient's  head. 
The  dam  should  pass  between  the  thumb  and  index  finger  and  out 
again  between  the  third  and  little  fingers,  so  that  the  index,  second, 
and  third  fingers  are  exposed  to  the  operator's  view  as  he  looks  at 
the  back  of  his  hand  while  the  ends  of  the  thumli  and  little  finger 
are  covered  by  the  dam.  The  grasp  of  the  dam  therefore  comes 
in  two  places,  between  the  thumb  and  index  finger  and  between 
the  third  and  little  fingers,  thus  keeping  the  dam  on  a  tension  and 
leaving  the  second  finger  free  to  stretch  the  holes.  The  end  of 
the  second  finger  should  be  placed  at  the  upper  margin  of  the  hole 
which  is  to  embrace  the  tooth  farthest  to  the  left,  and  opposite 
this,  on  the  lower  margin  of  the  same  hole,  should  be  placed  the 
end  of  the  index  finger  of  the  right  hand,  while  the  rubber  extends 
from  this  down  into  the  palm  of  the  right  hand  and  is  grasped  by 
gathering  the  edge  nearest  the  operator  between  the  thumb  and 
palm  on  the  one  side  and  the  second,  third,  and  little  fingers  on 
the  other,  the  thumb  extending  between  the  dam  and  the  patient's 
chin,  while  the  ends  of  the  fingers  are  curled  well  up  into  the  palm 
to  readily  lu-ing  the  ruliber  on  a  tension.  This  leaves  the  index 
finger  free  to  work  in  conjunction  with  the  second  finger  of  the 
left  hand  in  stretching  and  forcing  the  holes  over  the  teeth. 
(Fig.  29.) 

Beginning  with  the  tooth  farthest  to  the  left,  the  dam  should 
be  carried  consecutively  over  each  tooth  toward  the  right  till  all 
are  included.  The  strips  of  dam  between  the  holes  should  be 
forced  well  into  the  interproximal  spaces  by  a  see-sawing  or 
sti-etching  niorion  exerted  by  the  second  finger  of  the  left  hand 
and  the  in<U'X  finger  of  the  right,  so  that  if  possible  the 
edges  of  th<-  dniii  iii-ontid  the  hok's  are  turned  under  the  free 
margin  of  the  ^iims  hikI  h>ok  rootwiso.      The  outer  edges  of  the 


70 


PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 


dam  may  now  be  fastened  back  with  the  hokler,  after  which  liga- 
tures may  be  applied  wherever  necessary,  and  the  comfort  of  the 
patient  looked  after  as  previously  indicated. 

For  the  anterior  teeth  of  the  lower  jaw  the  grasp  of  the  rubber 
in  the  left  hand  is  practically  the  same  as  for  the  upper  teeth,  but 
the  grasp  with  the  right  hand  is  entirely  different.  Instead  of 
gathering  the  edge  of  the  dam  nearest  the  operator  in  the  palm^ 

Fig.  29. 


the  grasp  is  made  from  the  lower  margin  of  the  dam  with  the 
thumb  uppermost.  The  grip  is  exerted  by  curling  all  four  fin- 
gers up  into  the  palm  and  gathering  the  lower  edge  of  the  rubber 
between  the  ends  of  the  fingers  and  the  palm.  This  leaves  the 
thumb  free  to  stretch  the  holes  over  the  teeth  in  conjunction  with 
the  second  finger  of  the  left  hand  (Fig.  30).  But  the  method  of 
forcing  the  dam  to  place  is  different  from  that  of  the  upper  teeth. 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS.  «i 

When  stretching  the  holes  over  the  upper  teeth  the  end  of  the 
second  finger  of  the  left  hand  is  carried  along  the  labial  surface 
of  the  tooth,  while  with  the  lower  teeth  it  is  carried  into  the  mouth 
and  along  the  lingual  surface,  the  thumb  forcing  the  dam  over 
the  labial  surfaces. 

To  gain  an  intelligent  conception  of  the  methods  of  procedure 
here  outlined,  l)oth  as  regards  the  handling  of  the  clamp  forceps 

Fig.  30. 


and  the  various  grasps  of  the  rubber  dam,  the  beginner  would 
better  follow  out  the  descriptions  with  the  forceps  and  dam  in  his 
hands.  It  is  too  often  the  case  that  descriptions  which  read  well 
prove  imj)ractical)le  wlion  a])])lied  to  the  mouth,  wliile  methods 
whicli  ap[)ear  cumbrous  in  i)rint  are  very-effective  in  their  practi- 
cal application.  It  is  with  this  idea  in  mind  tliat,  in  conjunction 
with  the  writing  of  these  descriptions,  an  actual  adjustment  of  the 
dam  has  })een  made  in  each  instance. 


72  PKIiSrCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

Applying  the  Dam  for  Operations  on  Buccal,  Labial,  or  Lingual 

Cavities. 

The  pecuKar  difficulties  to  be  encountered  in  controlling  these 
cases  relate  to  the  rootwise  extension  of  the  decay,  and  the  conse- 
quent involvement  of  the  gum-tissue  in  the  cavity.  In  some  in- 
stan-ces  the  gum  fills  more  than  one-half  the  cavity,  and  the  prob- 
lem then  is  to  displace  the  gum  so  as  to  expose  the  gingival  margin 
of  the  cavity  and  admit  of  carrying  the  clamp  and  rubber  rootwise 
of  it.  This  may  be  done  in  one  of  several  ways.  Wliere  a  large 
mass  of  hypertrophied  gum-tissue  fills  the  cavity  it  should  be  cut 
away  with  a  lancet  or  curved  scissors,  and  then  the  cavity  packed 
with  gutta-percha  in  the  form  of  a  soft  temporary  stopping,  with 
considerable  excess  extending  over  the  gingival  margin  of  the 
cavity  so  as  to  force  the  gum  well  away  from  this  region.  This 
should  be  allowed  to  remain  two  or  three  days,  when  the  gum  will 
be  found  well  healed  and  the  cavity-margin  exposed.  In  many 
cases  the  temporary  stopping  will  accomplish  the  object  without 
previous  cutting  of  the  gum,  and  in  case  it  is  difficult  to  maintain 
in  place,  on  account  of  the  form  of  the  cavity,  it  may  be  secured 
by  passing  a  ligature  around  the  tooth  and  over  the  gutta-percha, 
thus  tying  it  to  position. 

In  some  cases  the  decay  extends  over  the  surface  of  the  tooth 
and  under  the  gum  for  considerable  distance  without  appreciable 
penetration  into  the  tooth,  so  that  gutta-percha  cannot  in  any  way 
be  employed  to  force  back  the  gum.     The  only  alter- 
FiG.  31.         native  is  to  press  away  the  gum  with  the  clamp  at 
the  time  of  operating,  or,  if  this  cannot  be  done,  to 
make  a  vertical  incision  in  the  gum  over  the  cavity, 
reaching  from  the  gum-margin  rootwise  past  the  de- 
cay.    The  flaps  of  gum  may  then  be  forced  out  of 
the  way,  and  after  the  operation  they  will  readily 
heal,  provided  care  is  taken  not  to  produce  too  much 
laceration.      (Fig.  31.) 
With  the  gingival  margin  of  the  cavity  thus  exposed  one  of  the 
chief  difficulties  in  the  application  of  the  dain  is  removed,  but  a 


EXCLUSION    OF    MOISTUEE    DURING    OPERATIONS.  73 

minor  one  instantly  presents  itself  in  the  fact  that  the  cavity 
extends  so  much  farther  rootwise  than  the  gum  on  the  opposite 
side  of  the  tooth  that  the  jaws  of  the  clamp  do  not  impinge  on  the 
tooth  at  points  directly  opposed  to  each  other.  This  results  in 
insecurity  of  the  clamp  unless  specially  provided  for.  With  the 
Keefe  clamp  this  difficulty  is  overcome  by  the  adjustable  jaws 
and  the  triple  bearing,  in  the  Libby  by  the  pivoted  shoe  for  the 
lingual  surface,  and  in  the  Dunn  by  the  use  of  the  gum  pad,  so 
that  the  points  of  bearing  may  be  arranged  directly  opposite  one 
another.  It  is  of  the  utmost  importance  to  test  the  various 
clamps  on  the  tooth  before  the  application  of  the  dam,  so  that  a 
suitable  selection  may  be  made  for  the  case  in  hand. 

In  making  holes  in  the  dam  for  these  cavities  they  should  be 
punched  farther  apart  than  for  other  cavities,  so  as  to  admit  of 
considerable  stretching  of  the  strips  between  the  holes  without 
drawing  them  too  thin  or  too  narrow. 

Application  of  the  Dam  in  Difficult  Cases. 

It  is  seldom  that  the  dam  cannot  be  readily  applied  to  any  of  the 
anterior  teeth  and  securely  retained  in  place,  but  with  the  molars, 
particularly  the  second  and  third  molars,  the  problem  sometimes 
becomes  more  or  less  complicated.  The  chief  difficulties  relate  to 
peculiar  forms  of  teeth,  unfavorable  positions  of  teeth,  bad  con- 
tacts on  the  proximal  surfaces,  and  a  general  tendency  to  resist- 
ance on  the  part  of  the  patient. 

The  forms  of  teeth  most  unsuited  for  the  retention  of  the  clamp 
are  those  of  a  cone-shape,  with  buccal  and  lingual  surfaces  so 
sloped  that  the  clamp  is  invariably  displaced  unless  made  of  a 
peculiar  pattern.  Teeth  of  this  character  are  much  larger  in  cir- 
cumference at  the  gum-margin  than  at  the  occlusal  surface,  and 
there  is  consequently  no  opportunity  for  the  grip  of  an  ordinary 
clamp.  But  if  a  close  study  be  made  of  these  teeth  it  will  usually 
be  found  that  a  short  distance  under  the  free  margin  of  the  gum 
there  is  a  slight  depression  as  the  enamel  approaches  its  thin  edge 
near  the  cernontiun.     The  gum  is  never  adherent  to  the  tooth  at 


74:  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

this  point,  and  with  a  clamp  so  formed  that  the  jaws  are  turned 
down  into  a  reasonably  sharp  projection  at  either  extremity,  so 
as  readily  to  slip  under  the  free  margin  of  the  gum,  an  adequate 
grip  may  be  obtained,  provided  the  patient  will  submit  to  a  slight 
temporary  discomfort.  Such  a  clamp  has  already  been  referred 
to  in  Fig.  20,  and  if  this  clamp  is  used  with  discriminating  judg- 
ment it  will  be  found  very  effective  without  the  infliction  of  any 
serious  pain.  It  should  be  applied  with  the  Brewer  forceps, 
the  bows  of  the  clamp  necessarily  being  very  rigid  and  the  jaws 
not  readily  spread  with  the  ordinary  forceps. 

Unfavorable  positions  of  the  tooth  relate  particularly  to  upper 
third  molars  which  are  turned  outward  so  that  their  occlusal  sur- 
faces look  somewhat  toward  the  cheek.  In  these  cases  it  is  often 
found  that  on  opening  the  mouth  the  anterior  border  of  the  ramus 
of  the  lower  jaw  is  carried  forward,  so  as  to  impinge  against  the 
bow  of  the  clamp.  This  difficulty  may  be  overcome  by  using  a 
clamp  with  a  small  bow  and  applying  it  in  the  following  way: 
After  carrying  the  clamp  into  the  mouth,  and  before  any  attempt 
is  made  to  place  it  over  the  tooth,  the  angle  of  the  lips  on  the 
side  of  the  operation  should  be  stretched  well  out  and  back  with 
the  fingers  of  the  left  hand,  so  as  to  expose  the  buccal  surfaces  of 
the  upper  molars  to  view ;  and  then  the  patient  should  be  instructed 
to  close  the  mouth  as  far  as  possible.  This  will  immediately  throw 
the  ramus  back  out  of  the  way  and  further  loosen  the  tension  of 
the  cheek  and  lips,  so  a  better  view  is  had  and  an  adequate  space 
left  to  slip  the  clamp  to  place.  It  will  be  found  that  in  operating 
on  these  teeth  there  is  little  necessity  for  keeping  the  jaws  very 
far  apart,  particularly  if  the  operator  is  expert  in  the  use  of  the 
mouth-mirror.  All  of  the  work  on  these  teeth  after  the  applica- 
tion of  the  dam  should  be  performed  through  the  reflection  of  the 
mirror,  with  the  operator  standing  erect.  By  this  method  these 
cases  are  readily  met  and  the  difficulty  overcome. 

In  some  instances  on  the  lower  jaw  the  ridge  of  bone  extend- 
ing forward  from  the  ramus  is  so  prominent  opposite  the  buccal 
surface  of  the  third  molar  as  to  interfere  with  the  application  of 
an  ordinary  clamp,   and  in  such  a  case  the  Southwick  clamp, 


EXCLUSION    OF    MOISTUKE    DURING    OPERATIONS.  75 

Fig.   32,   is  indicated.      This  clamp  is  made  in  four  sizes,   and 

should  be  in  every  operating  case.     It  is  often  applicable  to  the 

upper  teeth  as  well  as  the  lower. 

Bad    contacts    between    teeth,    interfering 

Fig   32 
most   seriously   with    the   adjustment   of   the 

dam,  are  found  in  cases  where  slight  decay 
has  commenced  near  the  contact  point,  leav- 
ing sharp  edges  of  enamel  calculated  to  cut 
the  dam,  and  also  where  there  has  been  exten- 
sive wear  of  the  teeth  un  the  proximal  surfaces  from  the  individual 
movement  of  the  teeth  one  against  the  other,  resulting  in  broad 
contacts  with  the  teeth  tightly  lodged  together.  Reference  has 
already  been  made  to  the  management  of  the  former  whereby  a 
thin  broad-bladed  instrument  is  forced  between  the  teeth  and  the 
sharp  edges  of  enamel  broken  down,  but  in  many  of  the  latter 
cases  it  is  impracticable  to  force  such  an  instrument  between  the 
teeth.  This  condition  of  worn  facets  on  the  proximal  surfaces  is 
often  associated  with  teeth  the  occlusal  surfaces  of  which  have  also 
been  worn  so  that  the  teeth  present  a  broad,  flat,  table-like  surface 
on  their  occlusal  aspect,  joining  at  a  sharp  right  angle  the  worn 
facet  on  the  proximal  surface.  With  teeth  of  this  character  pre- 
senting no  V-shaped  depression  or  slope  from  the  occlusal  surface 
to  the  contact  point,  as  in  normal  cases,  the  problem  of  entering  the 
rubber  between  the  teed;h  is  frequently  difficult.  In  every  such 
case  the  ligature  should  be  passed  between  the  contacts  in  advance 
of  the  rubber,  to  carry  away  any  small  particles  of  foreign  material 
that  may  be  lodged  between  the  teeth.  When  the  o])erator  is 
certain  that  all  the  spaces  are  free  the  dam  should  be  carried  over 
the  last  tooth  back  with  the  clamp,  and  then  the  strip  of  rubber 
between  that  tooth  and  the  one  in  front  of  it  should  be  brought  on 
a  stretch  over  the  contact  points  and  held  there  with  the  fingers  of 
the  left  hand,  one  finger  forcing  it  down  hard  upon  the  buccal 
festoon  of  gum  and  the  other  n])on  the  lingual  festoon.  While 
the  dam  is  thus  hung  up  over  the  junction  of  the  two  teeth,  the 
right  hand  may  be  employed  to  slightly  force  the  teeth  apart  by 
passing  the  end  of  a  thin-bladed  spatula  in  tlic  interproximal  space 


76  PRIIs^CIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

from  the  buccal  or  labial  aspect,  and  prying  on  the  teeth  with  a 
rotary  movement  of  the  spatula.  This  will  usually  force  the  teeth 
apart  sufficiently  to  allow  the  strip  of  rubber  to  glide  between 
them,  and  the  process  may  be  continued  from  one  contact  point  to 
another  till  all  of  the  teeth  are  embraced  by  the  dam. 

In  every  case  of  difficult  contact  the  passage  of  the  rubber  may 
be  facilitated  by  smearing  the  strips  between  the  holes  with  vase- 
line or  other  suitable  lubricant.  This  will  allow^  it  to  glide  more 
readily  past  the  tight  places,  but  care  should  be  exercised  not  to 
allow  any  of  it  to  come  upon  the  surface  of  the  dam  to  be  grasped 
by  the  fingers.  If  by  any  inadvertence  it  gets  on  this  surface  it 
will  instantly  destroy  all  possibility  of  securing  an  adequate  grasp, 
and  it  is  therefore  well  to  dispense  with  it  entirely  except  with 
teeth  presenting  particularly  difficult  contacts. 

Occasionally  the  operator  will  encounter  trouble  in  applying  the 
dam  in  cases  where  the  teeth  themselves  are  not  at  fault,  on  ac- 
count of  muscular  resistance  on  the  part  of  the  patient's  lips  and 
tongue.  Where  this  tendency  is  discovered  in  any  manipulation 
about  the  mouth  it  is  sometimes  advisable  to  hand  the  patient  a 
mirror  and  let  him  watch  the  movements  of  the  tongue  and  lips, 
and  see  to  what  extent  they  are  discommoding  the  operator.  With 
some  patients  this  is  a  sufficient  appeal  to  their  intelligence  to 
result  in  overcoming  the  impulse,  but  with  others  there  seems  to 
be  an  uncontrollable  tendency  to  resist  the  dam.  In  such  cases, 
where  it  is  impossible  to  bring  about  a  relaxation  of  the  muscles 
and  an  acquiescence  on  the  part  of  the  patient,  the  operator  would 
better  limit  the  application  of  the  dam  to  as  few  teeth  as  will  per- 
mit of  reasonable  access  to  the  work.  This  difficulty  is  ordinarily 
confined  more  particularly  to  the  lower  molars,  and  it  is  usually 
advisable  in  such  cases  to  let  the  application  of  the  dam  terminate 
at  the  first  bicuspid.  To  keep  the  dam  out  of  the  operator's  way 
and  to  hold  it  more  secure  against  displacement  from  the  action  of 
the  tongue  and  cheek,  it  is  often  a  most  excellent  plan  to  slip  a 
clamp  over  the  first  bicuspid  with  the  bow  looking  toward  the 
front  of  the  mouth.  A  strong  clamp  should  be  used  for  the  molar, 
and,  after  the  rubber  has  been  carried  to  place  as  best  it  may  till 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS.  77 

the  first  bicuspid  is  reached,  the  bicuspid  clamp  should  be  taken 
up  in  the  forceps  with  the  jaws  looking  away  from  the  forceps,  and 
the  clamp  forced  to  position  on  the  tooth.  The  dam  is  thus  secured 
at  either  extremity  of  its  application,  and  the  operator's  hands  are 
free  to  use  ligatures  and  carry  the  dam  past  the  contact  points  and 
further  perfect  its  adjustment.  This  method  will  often  save  the 
operator  much  annoyance  in  these  stubborn  cases. 

There  are  also  certain  cavities  which,  in  mouths  where  for  any 
reason  the  application  of  the  dam  is  difficult,  may  be  adequately 
protected  by  adjusting  the  dam  to  a  single  tooth.  Small  cavities 
in  the  occlusal  surfaces  of  molars  may  often  be  filled  in  this  way 
if  the  case  presents  peculiar  obstacles  to  the  extension  of  the  dam 
over  other  teeth.  But  the  disadvantages  of  operating  on  a  tooth 
under  such  conditions  render  it  advisable  to  limit  this  practice  to 
the  fewest  possible  number  of  cases. 

The  Use  of  Napkins  and  Cotton  Rolls  for  Maintaining  Dryness 
during  Operations. 

In  many  minor  operations,  where  the  time  necessary  for  their 
performance  is  quite  limited,  the  rubber  dam  may  well  be  dis- 
pensed with,  and  the  teeth  kept  dry  by  the  use  of  napkins  or  cotton 
rolls  made  for  this  purpose.  The  upper  teeth  are  more  easily  man- 
aged in  this  manner  than  the  lower  ones,  but  even  on  the  lower  jaw 
the  skillful  use  of  the  napkin  may  in  many  mouths  serve  a  useful 
purpose.  In  employing  napkins  or  rolls  for  the  exclusion  of 
moisture  consideration  should  be  had  for  the  points  at  which  the 
saliva  enters  the  mouth,  and  an  effort  should  be  made  to  control 
it  as  far  as  possible  at  the  location  of  its  entrance.  On  the  lower 
jaw  the  salivary  ducts  open  into  the  floor  of  the  mouth  under  the 
free  end  of  the  tongue,  or  just  in  front  of  the  attachment  of  the 
tongue  to  the  floor;  while  on  the  upper  jaw  the  ducts  open  from 
the  cheek  opposite  the  buccal  surfaces  of  the  molar  teeth. 

Napkins. 
Napkins  for  this  purpose  are  conveniently  made  from  a  piece 
of  clean  bleached  linen,  cut  to  the  desired  size  and  form  for  the 


78  PRINCIPLES    AND    PRACTICE    OF    PILLING    TEETH. 

case  in  hand,  and  after  being  used  once  should  be  thrown  away. 
To  exclude  moisture  from  the  lower  teeth  a  piece  should  be  cut 
sufficiently  long  to  reach  from  the  lingual  surfaces  of  the  molars 
on  one  side  around  under  the  tip  of  the  tongue  to  the  lingual  sur- 
faces of  the  molars  on  the  other.  It  should  be  wide  enough  so 
that  when  folded  into  a  pad  it  will  be  sufficiently  thick  to  fit  with 
some  pressure  between  the  tongue  and  the  lower  jaw,  but  not  so 
thick  that  the  tongue  is  discommoded  to  the  extent  of  rebelling 
against  it  and  forcing  it  out  of  position.  It  will  thus  be  seen  that 
the  size  must  vary  in  different  mouths. 

To  adjust  this  napkin  it  should  be  grasped  with  the  pliers  near 
one  end,  and  the  patient  instructed  to  raise  the  tongue  toward  the 
roof  of  the  mouth.  This  end  of  the  napkin  should  then  be  car- 
ried down  between  the  side  of  the  tongue  and  the  lower  jaw  be- 
neath the  lingual  surfaces  of  the  molar  teeth  on  one  side,  and  then 
the  napkin  passed  under  the  tip  of  the  tongue  immediately  over 
the  salivary  ducts  and  around  to  the  other  side  of  the  mouth  in  the 
same  way.  The  patient  should  then  be  instructed  to  allow  the 
tongue  to  rest  lightly  on  the  napkin,  but  cautioned  not  to  run  it 
under  the  napkin  and  lift  it.  This  protects  the  lingual  aspect  of 
the  teeth,  but  the  buccal  surfaces  require  attention  to  guard  against 
the  saliva  which  flows  down  the  cheek  from  Steno's  duct.  If  the 
duct  is  located  quite  far  up  on  the  cheek  it  may  be  guarded  by 
packing  a  short  napkin  between  the  cheek  and  the  upper  teeth, 
but  if  the  opening  is  low  the  saliva  is  likely  to  trickle  down  along 
the  cheek  and  reach  the  lower  teeth.  The  only  alternative  is  to 
place  a  plump  napkin  along  the  buccal  surfaces  of  the  lower  molars 
and  bicuspids,  and  hold  it  against  the  cheek  and  gum  with  the 
fingers.  The  saliva  will  of  course  flow  down  from  the  upper  duct, 
but  it  will  be  absorbed  by  the  thick  napkin  and  not  reach  the 
lower  teeth.  If  the  napkin  gets  too  much  saturated,  so  as  to 
endanger  leaking  against  the  teeth,  it  may  be  adroitly  removed 
and  replaced  by  a  dry  one. 

In  some  instances  the  adjustment  of  the  napkin  over  the  open- 
ings of  the  ducts  will  effectually  stop  all  saliva  from  entering  the 
mouth,  and  under  these  conditions  the  napkin  becomes  adherent 


CLASSIFICATIOX    AXD    PREPARATION    OF    CAVITIES.  79 

to  the  dried  nnieous  membrane,  and  must  be  removed  with  the 

greatest  caution  through  fear  of  injuring  the  membrane. 

In  excluding  moisture  from  the  upper  teeth  with  the  napkin,  it 

is  necessary  only  to  pack  against  the  opening  of  Steno's  duct  by 

placing  the  napkin  between  the  cheek  and  the  upper  jaw  above 

and  against  the  buccal  surfaces  of  the  molars  and  bicuspids.      To 

prevent  the  patient  from  closing  the  mouth  and  moistening  the 

cavity  with  the  tongue,  a  mouth-mirror  should  invariably  be  held 

as  a  guard  under  the  upper  teeth  in  such  a  way  as  to  protect  the 

operation. 

Rolls. 

To  provide  a  more  convenient  means  than  the  use  of  the  napkin, 
cotton  rolls  were  devised  and  placed  on  the  market.  They  are 
furnished  by  the  manufacturers  in  various  sizes,  and  in  lengths 
sufficient  to  enable  the  operator  to  cut  them  to  suit  any  individual 
case.  They  are  effective  for  very  short  operations, — particularly 
upon  the  upper  teeth, — but  they  have  not  the  same  range  of  ser- 
vice that  has  a  napkin  properly  applied.  It  is  seldom  that  they 
can  be  maintained  in  place  if  passed  from  the  lingual  surfaces  of 
the  molars  on  one  side  of  the  lower  jaw  to  the  molars  on  the  other 
side,  and  their  use  is  therefore  practically  limited  to  one  side  of 
the  mouth.  They  are  not  so  effective  in  guarding  the  orifices  of 
the  ducts  as  are  napkins,  and  must  depend  chiefly  upon  their 
absorptive  properties  for  gathering  up  the  saliva  as  it  flows  against 
them.  But  they  should  be  found  in  every  operating  case,  on 
account  of  their  great  convenience  in  the  limited  number  of  cases 
to  which  they  are  suited. 


CHAPTER    V. 

CLASSIFICATION  AND  PKEPAKATION  OF  CAVITIES. 

The  following  Ijrief  classification  of  cavities  is  adapted  from  tlie 
report  of  the  Committee  on  Syllabus  presented  to  the  Institute  of 
Dental  Pedagogics,  and  adopted  by  that  body. 


80  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

Cavities,  as  to  character,  are  divided  into  two  general  classes: 
pit  and  fissure  cavities,  and  smooth  surface  cavities. 

Pit  and  fissure  cavities  are  those  occurring  as  the  result  of 
structural  imperfections  in  the  enamel  due  to  faulty  development, 
whereby  two  or  more  islands  of  calcification  in  approaching  each 
other  have  failed  to  grow  together  or  coalesce,  leaving  a  break  in 
the  continuity  of  the  enamel-covering.  This  defect  results  in  the 
admission  of  the  micro-organisms  of  decay,  and  forms  a  harbored 
shelter  in  which  they  may  work  their  destructive  processes  un- 
molested. 

These  cavities  are  found  in  the  occlusal  surfaces  of  bicuspids 
and  molars,  in  the  lingual  surfaces  of  upper  incisors,  and  in  the 
occlusal  two-thirds  of  the  buccal  and  lingual  surfaces  of  molars. 
It  will  thus  be  seen  that  they  occur  in  surfaces  which  are  ordi- 
narily kept  clean  by  the  friction  of  food  in  mastication  or  by  the 
tongue  or  cheeks,  and  are  therefore  directly  traceable  to  faults  in 
the  enamel-structure. 

Smooth  surface  cavities  are  those  occurring  in  surfaces  where 
the  enamel  is  perfectly  formed,  but  where  the  location  is  such  that 
it  is  not  ordinarily  kept  clean  by  friction.  They  are  thus  dis- 
tinctive in  character  from  pit  and  fissure  cavities,  both  as  regards 
the  conditions  which  bring  them  about  and  the  methods  to  be 
employed  in  their  preparation.  These  distinctions  will  receive 
more  detailed  consideration  later. 

Cavities  under  this  head  occur  in  the  proximal  surfaces,  and  in 
the  gingival  third  of  labial,  buccal,  or  lingual  surfaces. 

Cavities,  as  to  extent  and  location,  are  divided  into  simple  cavi- 
ties and  complex  cavities. 

Simple  cavities  are  those  involving  only  one  surface  of  a  tooth, 
as  an  "occlusal"  cavity,  a  "buccal"  cavity,  a  "labial"  cavity,  etc. 

Complex  cavities  are  those  involving  two  or  more  surfaces,  as  a 
"mesio-occlusal"  cavity,  a  "disto-labial"  cavity,  a  "mesio-disto- 
occlusal"  cavity,  etc. 

Cavities  are  named  according  to  the  surfaces  of  the  teeth  in 
which  they  occur,  and  cavity-walls  are  named  according  to  the 
surface  or  anatomical  landmark  toward  which   they  approach. 


CLASSIFICATION    AND    PREPAKATION    OF    CAVITIES.  81 

Examples:  In  a  mesio-occlusal  cavity  in  an  upper  bicuspid  the 
buccal  wall  is  that  wall  which,  if  extended  far  enough,  would 
involve  the  buccal  surface  of  the  tooth;  the  gingival  is  that  wall 
which,  if  extended  far  enough,  would  involve  the  gingival  line. 
In  an  occlusal  cavity  in  a  lower  molar  the  bottom  or  floor  of  the 
cavity  is  called  the  pulpal  wall,  and  in  case  of  death  of  the  pulp, 
so  as  to  involve  the  pulp-chamber,  the  floor  then  becomes  the  sub- 
pulpal  wall. 

An  axial  surface  of  a  tooth  is  any  surface  parallel  with  the  long- 
axis  of  the  tooth,  and  an  axial  wall  is  that  wall  which  approaches 
the  pulp  in  a  cavity  in  an  axial  surface. 

CAVITY  PREPARATION. 

Proximal  Cavities  in  Incisors  and  Cuspids. 

Simple  cavities  not  involving  the  incisal  angle. — When  decay 
occurs  in  thq  proximal  surfaces  of  any  of  the  anterior  teeth,  we 
are  confronted  with  problems  peculiar  to  the  locality.  The  first 
consideration,  as  in  every  other  class  of  cavities,  is  of  course  the 
preservation  of  the  teeth,  but  in  these  exposed  positions  we  must 
not  ignore  esthetic  and  artistic  effects  if  we  would  do  the  highest 
class  of  service.  Were  it  possible  for  us  to  save  these  teeth  by 
filling  without  advertising  the  fact  to  the  world,  it  would  be  our 
manifest  duty  to  do  so;  but  unfortunately  this  cannot  always  be 
done.  It  may  also  be  stated  that  in  the  attemjit  to  hide  our  work 
by  confining  our  fillings  to  narrow  areas  we  often  jeopardize  the 
teeth  and  lessen  the  confidence  of  the  public  in  the  permanence 
-of  dental  operations  through  recurrence  of  decay  and  consequent 
undermining  of  the  tooth-structure. 

01  (Servant  operators  have  noticed  that  there  are  certain  points 
around  ordinary  proximal  fillings  where  decay  is  most  likely  to 
recur.  This  relates  in  anterior  teeth  to  the  gingivo-labial,  gingivo- 
lingual,  and  the  incisal  angles.  The  reason  for  this  is  found  in  the 
fact  that  these  regions  are  not  kept  clean  by  the  friction  of  food  in 
mastication,  or  by  the  lips  or  tongue  in  their  various  movements, 
Jf  tlif  anatomical  relation  of  the  [(roxinial  surfaces  of  these  'teeth 

0 


82  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

is  studied,  it  will  be  seen  that  a  considerable  area  in  the  vicinity  of 
the  contact  point  is  not  self-cleansing.  This  is  what  admits  of 
caries  in  this  region  in  the  first  instance.  -  If  in  the  preparation  of  a. 
cavity  we  limit  the  area  to  a  small  round  outline,  we  have  left  un- 
protected, at  the  points  indicated,  more  or  less  of  the  surface  of 
enamel.  With  the  same  conditions  present  and  the  same  influ- 
ences at  work  which  originally  induced  decay,  there  is  little  to  pre- 
vent a  recurrence.  The  remedy  lies  in  so  extending  the  outlines  of 
the  cavity  that  the  margins  are  carried  to  a  point  where  they  will 
be  kept  clean.  This  process  has  been  termed  "extension  for  pre- 
vention"  by  Dr.  G.  V.  Black,  and  its  observance  must  be  insisted 
upon  where  the  most  permanent  work  is  required. 

Another  point  of  frequent  failure  around  these  fillings  is  along 
the  lingual  margin.  This  is  due  to  the  fact  that  the  lingual  wall  is 
often  left  exceedingly  thin,  and  the  enamel  is  crushed  under  the 
stress  of  mastication.  The  force  of  the  lower  incisors  comes  di- 
rectly against  this  surface^  and  any  unprotected  enaanel  is  likely 
to  be  broken  down.  In  every  instance  where  possible  the  margin 
should  be  so  extended  as  to  leave  the  enamel  well  supported  by 
dentine,  and  wherever  this  cannot  be  done  the  enamel  should  be 
freely  beveled  and  the  gold  built  over  it  in  such  a  manner  as  to  pro- 
tect it.  Enamel  protected  in  this  way  with  care  and  skill  will  re- 
main intact  in  ordinary  positions,  and  yet  this  does  not  alter  the 
general  rule  that  enamel  is  safest  when  supported  by  dentine. 

Fig.  33  shows  the  proximal  surface  of  an  incisor  with  a  small 
round  filling,  a,  points  of  recurrence  of  decay,  hhh,  and  the  outline 
to  which  the  cavity  should  be  carried  for  greatest  safety,  c. 

This  question  of  extension  is  a  matter  calling  for  the  most  care- 
ful consideration.  It  is  confidently  believed  to  be  a  solution  of  the 
problem  connected  with  a  very  frequent  form  of  failure  in  this 
class  of  cases,  and  yet  it  must  not  be  employed  indiscriminately. 
There  are  many  cases  where  it  would  be  manifestly  impossible  and 
injudicious  to  cut  the  cavity  to  the  extent  indicated.  Patients  ap- 
ply to  us  for  these  fillings  occasionally  in  such  a  nervous  condition 
that  any  extra  cutting  beyond  the  present  necessities  of  the  case 
must  be  avoided.     We  should  never  jeopardize  the  nervous  system 


CLASSIFICATIOX    AXD    rREPAEATIOX    OF    CAVITIES.  So 

of  our  patient  in  order  to  carry  out  some  heroic  theory.  Then, 
again,  there  are  persons  in  "whose  mouths  the  tendency  to  caries 
is  so  slight  that  extension  for  prevention  would  appear  to  be  an  un- 
necessarily extreme  measure.  In  some  of  these  cases  where  there 
is  limited  decay,  small  fillings  may  prove  serviceable  for  years, 
The  age  of  the  patient  also  has  an  important  ])earing  on  the  ques- 
tion. A\'henever  we  find  the  proxinuil  surfaces  l)reaking  down 
raj)idly  under  decay  early  in  life,  we  may  infer  that  the  process  of 
caries  is  to  be  active  in  that  mouth,  and  we  must  employ  the  most 
strenuous  means  to  control  it.  Extension  for  prevention  is  here 
indicated  to  its  fullest  legitimate  extent.  But  in  a  patient  well 
toward  maturity  with  an  occasional  cavity  developing,  we  may 
often  safely  stop  short  of  the  most  extreme  cutting.  Then  esthetic 
reasons  play  an  important  part  in  the  anterior  teetli.     If  we  can 

Fig.  ?,?j.  Fig.  31.  Fig.  35. 


.  hide  our  fillings  from  view  we  should  do  so,  and  many  of  our 
patients  are  Avilling  to  take  the  chances  of  a  recurrence  of  decay 
rather  tlian  have  large  fillings  made  in  the  first  instance.  A  dis- 
tinct understanding  should  be  had  with  patients  upon  these  points, 
so  that  they  may  enter  intelligently  into  the  merits  of  the  different 
methods.  AVe  should  be  sufficiently  honest  with  them  to  proceed 
on  the  theory  that  wherever  these  small  hidden  fillings  are  inserted 
the  work  must  be  considered  more  or  less  temporary,  and  must  be 
kept  niider  constant  surveilhmce  by  the  dentist. 

In  l)rief,  the  operator's  attitude  toward  the  ])i-actice  of  extension 
-lion Id  be  to  aim  always  at  the  mo.st  ideal  and  permanent  form  for 
lii-  cavities,  and  in  every  instance  where  he  deviates  from  this  it 
iiinst  be  oidy  on  account  of  some  well-defined  reason  for  doing  so. 

There  is  one  feature  connected  with  the  appearance  of  fillings  in 
tlif  anterior  teetli  which  mnst  not  be  ovei'lookc(l.  As  has  been 
said,  it   \-  sometimes  well   to  keep  fillings  from   view  if  |)ossi1)h'. 


84  PEIXCIPLES    AND    PRACTICE    OF    FILLIIfCf    TEETH. 

but  Avlienever  it  becomes  necessary  for  a  filling  to  show  at  all  it 
should  be  extended  labially,  so  as  to  show  distinctly.  The  reason 
for  this  is  that  where  gold  is  placed  between  teeth  in  such  a  way 
that  it  is  in  the  shadow,  the  appearance  a  few  feet  distant  from  the 
patient  is  that  of  a  black  mass  simulating  decay,  while  if  the  filling 
is  carried  out  sufficiently  to  allow  the  rays  of' light  to  reflect  upon 
it  the  bright  yellow  tinge  of  gold  is  immediately  perceptible. 
There  should  therefore  be  very  little  compromise  between  a  filling 
kept  entirely  out  of  sight,  and  a  good,  bold  showing  of  the  gold 
from  the  labial  aspect.     Figs.  34  and  35  illustrate  this  point. 

Separating  teeth. — The  first  requirement  in  operating  on  these 
cavities  is  to  have  sufficient  space  between  the  teeth  for  perfect 
access.  This  must  be  obtained  in  some  instances  by  wedging  pre- 
vious to  the  operation,  in  others  space  may  be  gained  while  oper- 
ating by  the  use  of  a  separator.  In  cases  where  the  teeth  have 
fallen  together  to  any  appreciable  extent  as  the  result  of  deep 
proximal  decay,  or  where  the  teeth  overlap  in  a  slight  irregularity, 
the  separator  will  ordinarily  not  gain  sufficient  space  for  a  proper 
contour  of  the  filling,  j^either  can  we  gain  access  to  do  perfect 
work  on  small,  hidden  cavities  (in  those  cases  where  it  may  be 
deemed  advisable  to  fill  in  that  manner)  short  of  extensive  separa- 
tion. Where  the  lal:)ial  or  lingual  wall  is  well  cut  away,  the  access 
is  simplified. 

The  methods  employed  for  gradual  separation  previous  to  op 
crating  may  be  varied  according  to  the  requirements  of  the  case. 
[Rubber  has  been  used  for  this  purpose  quite  extensively  in  the 
past,  but  it  is  only  in  the  rarest  cases  where  rubber  is  properly 
indicated.  The  difficulty  with  this  material  lies  in  the  fact  that  it 
cannot  easily  be  maintained  in  position.  The  sloping  surfaces  of 
the  teeth  tend  to  make  it  slide  away  from  the  contact  points 
and  insinuate  itself  into  the  interproximal  space  to  the  serious 
injury  of  the  gum-tissue.  Rubber  should  never  be  used  even  in 
the  extremest  cases  without  previously  protecting  the  gum  by  pack- 
ing cotton,  gutta-percha,  or  cement  against  the  gingival  wall  of  the 
cavity,  allowing  it  to  extend  across  the  interproximal  space  to  pre- 
vent the  movement  of  the  rubber  rootwise. 


CLASSIFICATIOX    AND    PREPAKATION    OF    CAVITIES.  85 

The  materials  best  adapted  for  separating  are  cotton,  gutta- 
percha, and  waxed  linen  tape.  Cotton  should  be  packed  firmly  be- 
tween the  teeth  while  dry,  and  if  there  is  difficulty  in  maintaining 
it  in  position  it  can  be  secured  by  passing  a  ligature  between  thd 
teeth  in  the  interproximal  space  before  placing  the  cotton,  and 
then  bringing  the  ends  down  over  it  toward  the  incisal  surfaces  of 
the  teeth  and  tying  tightly  around  the  cotton.  This  holds  it 
securely  in  place  and  proves  a  very  effective  means  of  separating 
teeth.     Fig.  36  illustrates  the  method  of  tying  the  cotton  in  place. 

Gutta-percha  may  be  employed  by  first  adjusting  the  separator, 
forcing  the  teeth  slightly  apart,  and  packing  the  gutta-percha  into 
the  cavity  and  firmly  l)etween  the  teeeth.  The  separator  is  then 
removed  and  the  gutta-percha  allowed  to  remain  for  several  days. 
This  will  usually  result  in  good  space  without  soreness. 

Waxed  linen  tape  of  a  suitable  width  for  the  case  in  hand  may 
profitably  be  employed  in  those  cases  where  there  has  been  little  or 
no  breaking  down  of  the  proximal  surfaces,  and  where  it  would 
be  difficult  to  retain  cotton  or  gutta-percha.  By  either  of  these 
methods  the  pressure  is  so  gradual  that  space  is  gained  without 
the  distressing  irritation  which  usually  accompanies  the  use  of 
ruVjber. 

In  favorable  instances,  or  in  emergency  cases,  space  may  be 
gained  at  the  time  of  the  operation  by  the  use  of  the  separator. 
Wherever  the  separator  is  indicated  it  should  be  used  in  the  fol- 
loAving  way:  Care  must  be  exercised  in  its  adjustment  not  to  allow 
it  to  impinge  on  the  gum  or  unnecessarily  wound  the  soft  tissues. 
It  should  not  be  tightened  to  the  limit  at  once,  but  merely 
"snugged  up"  till  the  patient  feels  it.  Then,  as  the  operation 
progresses,  it  can  be  gradually  tightened  at  intervals  without 
appreciable  discomfort.  By  the  time  the  cavity  is  prepared,  suf- 
ficient sijace  will  usually  have  been  gained  to  admit  of  the  inser- 
tion and  proper  contouring  of  the  filling,  and  then  a  slightly  addi- 
tional space  obtained  during  this  part  of  the  operation  will  afford 
opportunity  for  polishing.  When  the  filling  is  finished,  the  great- 
est caution  should  be  ol)servcd  in  removing  the  separator.  If  it  is 
loosened  suddenly  after  being  tightened  to  the  extent  usually  neces- 


86  pkijyciples  and  peactice  of  filling  teeth. 

sary,  it  will  result  in  most  excruciating  pain  to  the  patient,  the 
discomfort  from  this  source  ordinarily  being  greater  than  from  the 
process  of  separating.  It  should  be  loosened  veiy  gently  and 
slowly  till  the  contact  between  the  filling  and  the  tooth  next  in 
line  is  sufficient  to  hold  the  teeth  from  further  movement. 

In  manipulating  the  separator  the  greatest  delicacy  of  touch 
should  at  all  times  be  exercised.  It  is  a  dangerous  and  cruel  ap- 
pliance in  the  hands  of  the  thoughtless  or  careless.  The  operator 
should  invariably  employ  one  hand  to  steady  the  bows  while  the 
other  tightens  the  screws,  to  prevent  tilting  or  shifting  the  sepa- 
rator. Any  rocking  or  twisting  of  the  appliance  will  result  in  un- 
necessary pain,  and  undue  injury  to  the  soft  parts.  Another  seri- 
ous limitation  to  the  separator  lies  in  the  danger  to  enamel-margins 

Fig.  36.  Fig.  37. 


when  the  jaws  impinge  close  to  the  cavity.  The  enamel  may 
thereby  be  checked  in  such  a  way  as  to  jeopardize  the  usefulness  of 
the  filling  without  the  operator's  observation  of  the  fact  at  the  time. 
Cases  for  the  separator  should  be  selected  with  care  and  judgment, 
and  due  consideration  for  the  patient  must  invariably  accompany 
its  use.  With  these  precautions,  it  is  really  a  humane  appliance 
and  is  capable  of  a  large  range  of  usefulness.  It  is  not  only  indi- 
cated for  gaining  space  between  teeth,  but  may  frequently  be  used, 
where  space  has  already  been  obtained,  for  the  purpose  of  holding 
the  teeth  firm  during  the  operation.  This  avoids  in  large  measure 
any  soreness  from  malleting,  and  also  prevents  the  teeth  from  grad- 
ually dropping  together  while  the  filling  is  being  inserted. 

Wooden  wedges  may  also  be  used  occasionally  for  this  purpose, 
but  the  difficulty  with  wooden  wedges  lies  in  the  fact  that  they  are 
usually  injurious  to  the  gum-tissue  in  the  interproximal  space,  and 
their  entire  wedging  force  must  be  exerted  immediately  instead  of 
gradually.     Whenever  a  wooden  wedge  is  used  to  hold  the  teeth 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES.  87 

firm  during  an  operation  it  should  be  made  as  narrow  as  possible, 
and  the  rubber  dam  should  be  stretched  well  labially  before  the 
wedge  is  inserted,  to  overcome  the  tendency  which  the  dam  other- 
Avise  would  have  of  dragging  the  wedge  out  of  place.  Dr.  George 
E.  Hunt  suggests  as  an  expedient  to  prevent  the  rubber  from  snap« 
ping  the  wedge  out  of  place  to  take  a  thin  shaving  made  in  whit- 
tling the  wedge,  and  with  the  pliers  slip  it  into  the  interproximal 
space  with  its  side  against  the  rubber,  using  this  as  a  guard  for  the 

wedge. 

Detail  of  Cavity  Formation. 

After  frail  enamel-walls  have  been  broken  down  and  the  mar- 
gins extended  to  the  desired  outline,  all  decay  should  be  removed 
and  the  cavity  given  such  form  that  the  filling  will  be  retained 
securely  in  place. 

The  gingival  wall. — This  wall  should  be  extended  rootwise  suf- 
ficiently to  carry  the  margin  of  the  filling  well  under  the  gum  in 
accordance  with  Fig.  33.  The  line  d  reiDresents  the  gum  as  it 
€omes  down  between  the  teeth  in  the  interproximal  space,  and  the 
outline  of  the  filling  c  shows  the  gingival  portion  well  under  the 
gum.  The  reason  for  this  extension  is  the  well-known  fact  that 
wherever  we  have  the  gingival  portion  of  a  perfectly  inserted  fill- 
ing covered  1)y  healthy  gum-tissue,  we  will  never  have  recurrence 
■of  decay  at  that  point.  In  cases  where  the  enamel  has  begun  to 
take  on  a  whitened  appearance  at  the  gum-margin  extending 
gingivo-labially  and  gingivo-lingually  from  the  cavity,  thus  in- 
dicating an  approaching  disintegration,  or  where  the  activity  of 
the  carious  process  seems  to  be  very  great  in  that  mouth,  the  gingi- 
val outline  of  the  cavity  should  be  carried  well  out  gingivo-labially 
and  gingivo-lingually  as  illustrated  in  Fig.  37.  This  gives  the 
gingival  outline  a  curve  with  its  convexity  toward  the  cavity. 

The  gingival  margin  of  proximal  fillings  has  often  been  alluded 
to  as  the  "vulnerable  point,"  even  when  fillings  were  well  inserted, 
Init  this  is  hardly  in  strict  accordance  with  facts.  In  reality  decay 
seldom  recurs  along  the  gingival  margin  proper.  It  usually  begins 
at  the  gingivo-labial  (or  buccal)  and  gingivo-lingual  angles.  From 
here  it  may  extend  and  involve  the  entire  gingival  margin,  but  the 


88  PEINCIPLES    AND    PKACTICE    OF    FILLING    TEETH. 

initial  point  of  failure  is  usually  at  the  angles.  This  is  because 
there  is  a  lodgment-place  in  these  positions  for  deleterious  matter 
to  form  undisturbed  by  friction  from  the  tongue  or  lips,  and  un- 
j)rotected  by  gum-tissue.  In  this  small  sheltered  harbor  the  micro- 
organisms of  caries  create  their  films  and  attack  the  enamel.  No 
tooth  may  be  considered  safe  from  recurrence  of  decay  around 
proximal  fillings  unless  the  gingival  wall  has  been  carried  suffi- 
ciently rootwise  to  bring  that  portion  of  the  filling  under  the  gum. 
and  the  gingivo-labial  and  gingivo-lingual  angles  have  been  ex- 
tended to  a  point  where  these  margins  of  the  filling  are  kept  clean 
by  friction. 

This  form  of  extension  results  in  the  gingival  wall  being  either 
flat  labio-lingually  or  convex  toward  the  cavity,  and  this  is  be- 
lieved to  be  desirable  for  other  reasons  than  those  of  prevention. 
A  filling  is  more  easily  built  upon  a  flat  base  than  upon  a  curved 
base,  and  is  more  secure  from  dislodgment  when  completed.  The 
prevailing  custom  of  forming  the  gingival  wall  on  a  curve  labio- 
lingually  so  as  to  be  concave  toward  the  cavity  is  accountable 
for  the  fact  that  many  operators  find  their  fillings  rocking  when 
partly  inserted,  and  it  has  also  led  to  the  necessity  of  drilling  pits 
more  or  less  deep  (and  more  or  less  disastrous)  in  the  gingival 
portion  of  the  cavity. 

To  subserve  the  best  ends  in  anchorage  the  gingival  wall  should 
also  be  made  flat  mesio-distally,  with  a  slight  incline  rootwise  as 
the  gingival  wall  approaches  the  axial  wall.  In  some  instances  this 
incline  may  take  the  form  of  a  shallow  groove  in  the  dentine  ex- 
tending from  the  gingivo-labial  to  the  gingivo-lingual  angles  of  the 
cavity,  and  carried  somewhat  into  the  lingual  wall  at  this  point  to 
facilitate  the  starting  of  the  filling.  It  should  not  be  carried  to  any 
extent  into  the  labial  wall,  on  account  of  the  difficulty  of  adapting 
gold  into  an  inaccessible  undercut  such  as  this  would  be. 

The  lingual  wall. — As  has  already  been  intimated,  this  wall 
should  be  freely  cut  away  if  frail.  The  temptation  to  leave  it  for 
the  purpose  of  having  something  to  build  the  gold  against  in  the 
insertion  of  the  filling  has  proved  the  stumbling-block  of  many  an 
operator.     If  sufficiently  supported  by  dentine  it  need  not  be  ex- 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES.  89 

tended  farther  than  is  necessary  for  prevention,  but  in  some  in- 
stances it  must  be  cut  away  nearly  on  a  line  with  the  axial  wall. 

Especially  is  this  true  in  those  cases  where  for  esthetic  reasons 
it  is  considered  desirable  to  leave  the  labial  wall  standing  and  insert 
the  filling  mostly  from  the  lingual  aspect.  The  difficulty  of  doing 
a  perfect  and  permanent  operation  in  this  way  renders  these  cases 
rare,  and  limits  them  sharply  to  cavities  having  a  strong,  thick 
labial  wall. 

When  the  lingual  wall  is  cut  away  freely,  the  only  attempt  at 
retention  along  this  wall  should  be  as  it  approaches  the  gingivo- 
axial  angle  and  the  incisal  angle.  Here  a  right  angle  may  be  made 
with  the  axial  wall,  or  in  the  gingival  extremity  of  the  lingual  wall 
the  groove  previously  mentioned  in  the  gingival  wall  may  be  di- 
verted at  right  angles  into  the  gingival  third  of  the  lingual  wall. 
This  not  only  aids  in  retention,  but  provides  a  cul-de-sac  into  which 
may  readily  be  secured  the  first  pieces  of  gold.  Deep  grooving 
should  generally  be  avoided  in  these  cavities  on  account  of  the 
uncertainty  of  gaining  perfect  adaptation  and  density  of  the  gold 
in  the  bottom  of  grooves,  and  also  because  of  the  consequent  weak 
walls  to  the  cavity;  but  in  the  gingivo-lingual  region  these  ob- 
jections are  not  strictly  operative.  Direct  access  may  be  gained 
with  a  plugger,  and  the  bulk  of  tooth-tissue  covering  the  pulp 
at  this  point  admits  of  judicious  grooving  without  creating  weak 
walls.  But  in  no  instance,  even  where  it  is  deemed  advisable  to 
leave  the  lingual  wall  standing,  should  the  groove  be  extended 
throughout  the  length  of  the  wall.  The  most  that  should  be  done 
in  the  middle  third  of  the  wall  is  to  make  more  or  less  of  an  angle 
between  that  and  the  axial  wall. 

The  labial  wall. — The  same  general  rules  apply  to  the  formation 
of  this  wall  that  have  just  been  outlined  for  the  lingual  wall,  except 
that  grooving  is  contraindicated  in  any  portion  of  its  length.  In 
cases  where  possible  an  angle  may  be  formed  with  the  axial  wall 
to  increase  the  security  of  anchorage,  and  especially  should  this  be 
done  in  the  gingival  and  incisal  thirds. 

The  incisal  angle. — This  should  be  formed  at  right  angles  with 
the  axial  wall.     It  should  never  be  deeply  grooved,  nor  should  a 


'90  PRIISrCIPLES    AJiTD    PRACTICE    OF    FILLING    TEETH. 

pit  be  drilled  at  this  point,  as  is  frequently  done.  To  assist  in  re- 
tention of  the  filling  it  may  be  slightly  inclined  toward  the  incisal 
edge  of  the  tooth  as  it  approaches  the  axial  wall. 

The  axial  ivall. — The  form  of  the  other  walls  practically  deter- 
mines the  shape  of  this  walL  It  should  be  as  nearly  as  possible  at 
right  angles  with  the  others,  leaving  in  all  cases  as  much  dentine 
covering  the  pulp  as  is  consistent  with  strength  of  the  filling  and 
a  thorough  removal  of  all  decay. 

The  enamel-margins. — The  final  step  in  the  preparation  of  the 
cavity  is  the  treatment  of  the  margins.  The  enamel  should  be  so 
beveled  that  the  j)eripheral  ends  of  the  rods  are  cut  off  and  the  den- 
tinal ends  covered  with  gold  when  the  filling  is  inserted.  This 
calls  to  mind  the  necessity  for  introducing  two  terms  to  properly 
designate  enamel-margins.  In  reality  there  are  two  margins  to 
enamel,  and  in  cavities  such  as  we  are  considering  a  clear  distinc- 
tion between  the  two  is  important.  There  is  the  enamel-margin 
at  the  periphery  of  the  tooth,  and  the  enamel-margin  next  to  the 
dentine.  For  want  of  better  terms  these  may  be  designated  the 
peripheral  enamel-margin ,  and  the  dentinal  enamel-margin  (Fig. 
38,  a  and  &). 

If  in  all  cases  the  enamel  could  be  left  well  supported  for  con- 
siderable depth  by  dentine  the  distinction  in  terms  would  not  seem 
so  important,  but  this  is  not  ahvays  possible ;  and  where  such  is  the 
case  the  treatment  of  these  two  margins  is  dissimilar.  The  periph- 
eral margin  should  be  given  a  distinct  bevel,  while  the  dentinal 
margin  should  be  slightly  rounded. 

The  necessity  for  beveling  enamel  relates  to  the  peculiarity  of 
its  structure.  It  is  composed  of  rods  standing  with  their  ends  on 
the  dentine  and  radiating  out  toward  the  periphery  of  the  tooth  in 
a  more  or  less  regular  manner.  The  enamel  when  supported  by 
dentine,  and  with  no  break  in  the  continuity  of  its  structure,  will 
sustain  great  stress  without  fracture,  but  when  undermined  by 
decay  it  is  easily  broken  down.  This  break  is  usually  in  line  with 
the  enamel-rods,  which  indicates  that  the  cement-substance  holding 
the  rods  together  is  not  very  strong.  If,  then,  the  peripheral  ends 
of  the  rods  are  left  standing  around  a  filling  while  the  dentine  is 


CLASSIFICATIOX    AND    PKEPAKATIOX    OF    CAVITIES.  91 

gone,  and  possibly  the  dentinal  ends  of  the  rods  dissolved  out  by 
caries  or  bnrred  away  in  the  preparation  of  the  cavity,  it  is  readily 
seen  that  the  short  peripheral  rods  must  sooner  or  later  drop  out, 
even  if  they  escape  crushing  in  the  insertion  of  the  gold.  This 
admits  of  a  leak  around  the  tilling.  To  make  perfect  margins  the 
enamel  should  be  so  beveled  that  there  are  no  short  rods  at  the 
periphery.  But  this  bevel  must  not  be  too  acute,  nor  must  the 
peripheral  margin  be  rounded.  Either  of  these  conditions  would 
result  in  the  filling-material  assuming  too  attenuated  a  form  at  the 
edges,  which  would  admit  an  element  of  weakness  to  the  filling. 
The  exact  degree  of  bevel  cannot  well  he  given  in  figures,  owing 
to  the  variation  necessary  in  the  difi'erent  locations  along  cavity- 
margins  on  account  of  the  varying  direction  of  the  enamel-rods. 
The  degree  of  bevel  must  largely  be  governed  by  the  direction  of 
the  rods  in  each  particular  locality,  and  the  only  way  to  determine 
this  short  of  a  microscopical  examination,  which,  of  course,  is  im- 
practicable in  the  mouth,  is  by  the  sense  of  touch.  The  operator's 
fingers  may  lie  so  schooled  that  in  trimming  the  enamel  with  a 
sharj)  chisel  he  can  readily  determine  the  arrangement  of  the  rods 
by  the  ease  with  which  the  enamel  is  cleaved  in  certain  directions, 
llememberiiig  that  the  enamel  cleaves  most  readily  in  line  with  the 
direction  of  the  rods,  he  is  aide  to  intelligently  judge  the  condition 
of  the  margin  by  the  manner  in  which  the  blade  affects  it,  and 
so  long  as  the  perii)heral  portion  of  the  enamel  breaks  down  readily, 
or  is  easily  pulverized,  the  trimming  must  continue.  This  delicate 
"feeling"  along  the  margins  of  cavities  with  a  sharp  insti-mnent  is 
very  necessary  to  the  establishment  of  a  ])erfect  outline,  and  is  the 
only  true  criterion  as  to  the  degree  of  l)evel  indicated  in  each  given 
case. 

In  every  instance  Avhere  the  dentinal  enamel-margin  is  at  all 
prominent  it  should  be  slightly  rounded,  as  already  indicated,  to 
facilitate  tlie  ])erfect  adaptation  of  the  gold  against  it.  ( Fig.  39,  a, 
jH'ripheral  enamel-margin  lieveled,  h  dentinal  enamel-margin 
rounded,   c  filling-material   protecting  margin.) 

The  marginal  outlines  of  these  cavities  slioidd  represent  sym- 
metrical and  graceful  curves  that  will  not  offend  the  eye  of  the 


92  PRINCIPLES    A^^D    PRACTICE    OF    FILLING    TEETH. 

artist.  In  the  formation  of  the  walls  of  the  cavity,  angles  have 
been  recommended  at  various  points  for  the  firm  retention  of  the 
filling,  but  angles  are  never  permissible  along  the  margins  for 
esthetic  reasons.  As  the  gingival  margin  joins  the  labial  or  lingual 
margin  it  should  not  be  at  a  sharp  angle,  but  on  a  curve.  This 
curve  may  in  some  instances  be  rather  short,  but  it  must  invariably 
be  a  symmetrical  and  definite  curve.  The  outlines  along  the  labial 
and  lingual  walls  should  be  true  and  clearly  cut  to  present  the  most 
artistic  appearance.  The  dentist  should  aim  not  only  to  do  ser- 
viceable operations,  but  to  do  beautiful  ones  as  well. 

Technique. — The  first  step  in  the  operation  is  to  break  down  un- 
supported enamel-margins.  This  may  best  be  done  with  suitably 
formed  chisels,  made  sharp.  In  some  instances  the  thin  overhang- 
ing labial  wall  may  be  cleaved  away  to  advantage  with  a  short, 
strong  hatchet  excavator.  The  blade  must  not  be  long  enough  to 
penetrate  into  the  cavity  sufiiciently  to  expose  the  pulp  or  impinge 
on  sensitive  dentine  as  the  enamel  is  broken  in.  Care  should  be 
exercised  especially  in  the  early  stages  of  the  operation  not  to 
shock  the  patient.  A  false  movement  at  this  time  will  do  much 
to  unnerve  the  average  individual.  If  it  is  found  necessary  to  give 
pain  in  an  operation,  it  is  best  if  possible  to  defer  that  particular 
part  of  the  work  till  the  patient  has  been  some  minutes  in  the  chair. 
It  will  ordinarily  then  be  better  tolerated. 

After  weak  walls  are  broken  down  the  cavity  should  be  extended 
to  its  proper  outlines.  This  can  usually  be  done  rapidly  and  effect- 
ively with  sharp  burs,  either  round  or  oval  as  the  case  demands. 
In  the  use  of  burs  for  this  purpose — or  in  fact  for  any  purpose — 
due  regard  must  be  exercised  for  maintaining  the  bur  precisely  at 
the  angle  and  in  the  position  required.  ISTo  operator  should  ven- 
ture to  use  an  instrument  like  the  dental  engine  without  previously 
having  acquired  an  absolute  control  of  the  hand-piece,  and  having 
studied  carefully  its  dangers  and  limitations  as  well  as  its  legiti- 
mate uses.  The  failure  of  operators  to  properly  manipulate  the 
engine  is  accountable  for  much  of  the  prejudice  against  it.  The 
principal  dangers  to  be  guarded  against  in  extending  these  proxi- 
mal cavities  in  incisors  relate  to  the  displacement  of  the  bur  by 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES.  93 

catching  the  blades  against  the  margins  of  enamel  and  carrying  the 
bur  either  into  the  cavity  or  out  across  the  surface  of  enamel.  To 
prevent  this  the  hand-piece  should  be  firmly  grasped  and  the  bur 
applied  to  the  margin  without  too  much  force,  and  at  such  an  angle 
that  it  may  be  maintained  in  position. 

If  the  cavity  is  one  which  looks  toward  the  operator,  the  bur  may 
be  held  at  right  angles  with  the  long  axis  of  the  tooth,  and  in  that 
position  it  is  not  likely  to  slip.  In  cavities  looking  away  from  the 
operator  where  the  position  of  the  bur  is  more  nearly  parallel  with 
the  long  axis  of  the  tooth,  the  shank  of  the  bur  should  have  a  bear- 
ing on  the  surface  of  the  enamel  in  such  a  way  that  the  l)ur  will  be 
braced  against  the  displacement  while  the  blades  are  playing  along 

the  margins. 

Fig.  39.  Fig.  40. 

,o 

i 

After  the  cavity  has  been  extended  to  the  desired  outlines  the 
decalcified  dentine  should  be  removed.  This  is  ordinarily  best 
done  with  thin,  sharp  excavators,  though  in  some  instances  the 
same  bur  which  extended  the  outlines  may  be  used  for  a  few  revo- 
lutions to  remove  the  diseased  tissue.  In  those  cases  where  the 
decay  has  penetrated  to  any  extent,  this  work  should  be  done  with 
spoon  excavators  to  avoid  needless  pulp-exposure.  An  instrument 
with  a  sharp  angle,  as  in  the  hatchets  and  hoes,  is  more  likely  to 
penetrate  too  far  and  puncture  the  pulp  than  one  with  a  rounded 
form  such  as  the  spoons. 

AVhen  the  carious  tissue  is  removed  the  walls  should  be  shaped 
for  anchorage.  For  the  gingival  wall  an  inverted  cone  bur  of  suita- 
l)]e  size  should  be  placed  with  its  end  against  this  wall,  and  the 
shank  as  nearly  as  may  be  parallel  with  the  long  axis  of  the  tooth. 
It  is  then  carried  labially  and  lingually  along  the  gingival  -vvall  till 
the  pi-oper  form  is  secured.  The  end  of  the  l)ur  leaves  the  gingival 
wall  flat,  and  produces  nearly  a  right  angle  between  the  gingival 
and  ii.xial  walls.      T\m  angle,  while  not  strictly  speaking  a  right 


94  PEiig'ciPLEs  a:st>  practice  of  filling  teeth. 

angle  (unless  the  bur  is  held  perfectly  parallel  with  the  tooth),  is 
sufficiently  so  for  practical  purposes,  and  the  form  left  by  the  bur 
presents  a  surface  parallel  with  the  end  of  the  plugger  point,  thus 
facilitating  the  adaptation  of  the  gold  against  this  wall.  In  cases 
where  necessary  the  gingival  wall  may  be  slightly  grooved  with  the 
bur,  but  in  every  instance  it  must  be  used  with  care  and  judgment 
to  avoid  too  deep  cutting  and  pulp-exposure. 

As  the  bur  reaches  the  gingivo-linguo-axial  angle  of  the  cavity 
it  may  be  withdrawn  crownwise  along  the  gingival  third  of  the 
lingual  wall,  making  a  slight  groove  at  this  point  as  before  advo- 
cated. This  groove  formed  by  the  side  of  the  bur  will  be  rounded. 
If  deemed  advisable  it  may  be  squared  out  with  an  excavator  to  an 
angle  with  the  axial  wall. 

The  labial  wall  is  formed  by  placing  the  inverted  cone  bur  with 
its  end  against  the  axial  wall  and  its  shank  at  right  angles  with  the 
long  axis  of  the  tooth.  By  carrying  the  bur  laterally  along  the 
labial  wall  from  the  gingival  wall  to  the  incisal  angle  the  side  of  the 
bur  will  give  form  to  the  labial  wall,  and  an  angle  will  be  created 
between  that  and  the  axial  wall. 

The  incisal  angle  of  the  cavity  may  be  formed,  in  cases  where 
there  is  suitable  access,  by  carrying  the  inverted  cone  bur  down 
into  this  angle,  cutting  sidewise,  with  its  end  facing  the  axial  wall. 
The  form  of  the  bur  gives  the  required  angle  between  the  incisal 
and  axial  walls.  Where  the  bur  cannot  be  placed  in  the  proper 
position  to  accomplish  this  purpose,  the  incisal  angle  may  be 
formed  with  small,  delicate  excavators,  and  in  the  entire  formation 
of  the  cavity  indications  may  point  to  the  use  of  excavators  instead 
of  burs.  It  is  believed  that  with  sharp  burs  carried  in  a  hand-piece 
under  perfect  control  more  effective  cutting  can  be  made  in  a  given 
time  than  with  hand  instruments,  and  yet  the  operator  must  not 
lose  sight  of  the  advantages  of  excavators  under  certain  conditions, 
nor  enslave  himself  to  the  prejudiced  following  of  any  one  method 
under  'all  circumstances.  He  should  study  the  mechanical  and  the 
nervous  requirements  of  the  case,  and  readily  adapt  himself  to  the 
most  serviceable  plan  of  procedure. 

The  enamel-mare-ins  mav  be  beveled  with  a  fine-bladed  round 


CLASSIFICATIOX    AND    PREPAEATIOX    OF    CAVITIES.  'J  5 

bill*  used  in  the  manner  advocated  for  cavity  extension,  or  they 
may  be  pLined  off  with  delicate  sharp  chisels,  as  the  case  indicates. 

General  Considerations. 

It  may  be  noted  that  some  of  the  suggestions  here  advanced 
relative  to  cavity  formation  appear  somewhat  radical  when  com- 
pared with  the  methods  generally  in  vogue  in  the  profession. 
The  advocacy  of  angles  between  the  walls  of  these  cavities  may 
impress  many  as  being  illogical  and  impracticable  in  view  of  the- 
orthodox  teaching  on  the  subject.  Curved  outlines  to  cavity-walls 
have  usually  been  suggested  whenever  there  has  been  any  sugges- 
tion at  all.  This  has  been  done  with  a  view  of  making  a  cavity 
into  which  the  filling-material  might  easily  be  adapted,  and  one  of 
the  first  objections  likely  to  be  urged  against  the  formation  of 
angles  is  the  supposed  difficulty  of  adapting  gold  into  such  angles. 
This  question  of  the  non-adaptability  of  gold  to  angles  has  been 
much  overdrawn.  It  is  simply  a  matter  of  proper  manipulation,^ 
with  pluggers  of  a  suital)le  form  to  carry  the  gold  into  the  angle. 
It  need  not  here  be  stated  that  a  plugger  with  a  round  shank  and  a 
flat  serrated  face  is  not  the  form  for  this  purpose. 

Gold  can  easily  and  accurately  be  adapted  into  a  sharp  right 
angle,  as  has  repeatedly  been  proved  by  experiment.  The  advan- 
tages of  making  angles  in  cavities  relate  to  the  ease  with  which 
fillings  may  be  started  in  such  cavities,  and  the  unquestioned 
security  of  anchorage  without  undermining  and  weakening  the 
walls.  Fillings  built  upon  flat  bases  have  a  greater  stability  against 
displacement  under  stress  than  those  built  \ipon  curved  bases,  and 
tlie  gold  is  less  likely  to  rock  during  its  insertion. 

It  will  be  found  that  in  the  practical  application  in  the  mouth  of 
the  methods  here  advocated  it  is  seldom  that  a  perfectly  sharp  angle 
is  ever  made  in  one  of  these  cavities,  especially  in  any  position 
where  it  is  at  all  difficult  to  fill.  The  principle  involved  is  merely 
the  formation  of  flat  walls  instead  of  curved  walls,  and  the  operator 
who  makes  the  trial  of  building  fillings  against  flat  walls  after  being 
afcnstomed  to  curved  walls  will  not  long  remain  in  doubt  as  to 
whicli  i-  tlic  prfff-ralilc  iin'tliod.      Tlicrc  is  a  sense  of  security  to 


96  PRIjVrCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

the  work  as  it  progresses  which  is  never  experienced  when  the 
walls  have  been  formed  in  curves. 

Fig.  40  shows  a  longitudinal  section  of  a  tooth  mesio-distally, 
Avith  cavity  formed  and  filled.  It  will  be  seen  that  the  filling  is 
mortised  or  dovetailed  into  place,  with  no  deep  grooves  or  under- 
cuts to  weaken  the  walls. 

Proximal  Cavities  in  Anterior  Teeth  Involving  the  Incisal  Angle. 

When  caries  has  progressed  so  far  that  the  proximo-incisal 
angle  is  either  broken  down  or  so  undermined  that  it  is  unsafe  to 
leave  it,  the  problem  of  anchorage  becomes  correspondingly  com- 
plicated. With  this  angle  gone  and  the  consequent  necessity  for 
its  reproduction  in  gold,  an  additional  area  of  filling  is  exposed  to 
stress  tending  to  its  dislodgment.  The  usual  plan  of  anchoring 
these  fillings  has  been  to  groove  the  gingival  wall  deeply,  with  addi- 
tional grooves  along  the  labial  and  lingual  walls  wherever  pos- 
sible, and  then  drill  for  anchorage  in  the  incisal  region  between 
the  lingual  and  labial  plates  of  enamel  as  they  approach  each  other 
near  the  incisal  edge.      (Fig.  41.) 

While  many  fillings  anchored  in  this  manner  have  stood  the  test 
for  years,  and  while  there  are  some  instances  in  which  this  is  the 
only  practical  method  of  anchorage,  it  is  confidently  believed  that 
for  the  majority  of  cases  there  is  a  better  and  safer  means  at  hand. 
The  limitations  of  this  method  relate  to  the  fact  that  any  tipping 
stress  upon  such  a  filling  has  a  tendency  to  lift  it  away  from  its 
incisal  anchorage,  and  either  loosen  it  entirely,  or  so  dislodge  it  as 
to  cause  a  leak  along  the  incisal  half  of  its  outline.      (Fig.  42.) 

To  more  securely  anchor  these  fillings  at  their  incisal  extremi- 
ties, it  is  recommended  to  create  a  step  at  right  angles  with  the 
main  body  of  the  filling  by  cutting  a  groove  along  the  incisal  edge, 
or  rather  by  cutting  away  the  incisal  portion  of  the  lingual  plate  of 
enamel  to  a  sufficient  depth  and  length  to  gain  strength  of  filling- 
material.  The  labial  plate  of  enamel  is  ordinarily  left  standing 
for  appearance,  so  that  while  more  gold  is  used  in  this  kind  of  a 
filling,  the  excess  is  presented  to  the  lingual  aspect  of  the  tooth, 
Fig.  43,  and  there  is  no  greater  exposure  of  gold  to  the  labial  aspect 


CLASSIFICATION    AND    PREPAKATIOX    OF    CAVITIES. 


97 


than  ill  the  ordinaiy  contour  filling.  The  advantage  of  this  form 
of  anchorage  must  appeal  to  every  mechanical  mind.  A  filling 
properly  placed  in  such  a  cavity  cannot  be  dislodged  short  of  frac- 
ture of  the  filling  or  stretching  of  the  gold  from  repeated  impacts 
of  the  lower  tooth  at  the  point  where  the  main  body  of  the  filling 
joins  the  step.  Stress  brought  to  bear  on  such  a  filling  in  the 
process  of  biting  has  a  tendency  to  force  the  filling  into  the  cavity 
instead  of  lifting  it  away,  as  in  the  usual  methods  of  anchorage. 

Detail  of  Cavity  Formation. 

The  same  general  plan  of  formation  is  followed  in  the  gingival 
third  of  the  cavity  that  was  advocated  for  simple  proximal  cavi- 
ties, except  that  the  anchorages  may  be  made  deeper,  and  if  pos- 
sible broader,  for  the  contour  filling. 

The  labial  ivall. — This  wall  should  be  formed  as  nearly  as  possi- 
ble at  definite  right  angles  with  the  axial  wall.  The  creation  of  an 
angle  at  this  point  is  a  matter  of  importance  in  all  cases  where  the 


Fig.  41.       Fig.  42. 


Fig.  48. 


Fig.  44. 


Fig.  45. 


Fig.  46. ~ 


i 

extent  of  the  labial  wall  will  permit  it.  The  direction  of  stress 
against  these  fillings  by  the  lower  incisors  is  often  obliquely  up- 
ward and  toward  the  labial  (Fig.  44),  and  the  broader  we  can  make 
the  area  of  resistance  to  this  stress  the  more  securely  will  we  retain 
the  filling.  The  open  aspect  of  these  cavities  renders  the  adapta- 
tion of  gold  into  such  an  angle  very  convenient.  The  labial  wall 
of  the  step  should  have  the  same  form  and  same  angle  between  it 
and  the  .seat  of  the  step  or  pulpal  wall.  This  portion  of  the  labial 
wall  should  be  left  as  thick  as  possible  to  prevent  the  gold  from 
showing  through  and  to  represent  considerable  strength.     In  those 

7 


98  PRINCIPLES    AND    PEACTICE    OF    FILLING    TEETH. 

teeth  where  the  incisal  edge  is  so  thin  that  there  is  no  opportunity 
for  leaving  an  adequate  labial  plate  it  may  be  necessary  to  shorten 
the  labial  wall  somewhat  and  build  the  gold  over  it  so  as  to  expose 
it  to  view  from  the  labial  aspect.  (Fig.  45.)  In  such  a  pro- 
cedure artistic  appearance  is  sacrificed  for  safety. 

In  every  instance  where  this  wall  is  left  standing,  it  should  be 
beveled  as  illustrated  in  Fig.  46,  and  the  gold  built  over  the  bevel 
with  the  greatest  care.  Protected  in  this  way,  it  is  often  possible 
to  retain  this  wall  with  safety,  and  thus  disguise  our  operation  to 
that  extent. 

In  considering  the  strength  of  this  wall  an  objection  may  be 
urged  by  some  against  the  formation  of  an  angle  to  the  cavity  at 
the  junction  of  the  labial  with  the  other  walls,  on  the  mechanical 
ground  that  whenever  a  fracture  occurs  it  is  more  likely  to  locate 
itself  at  an  angle  than  at  any  other  place.  In  view  of  the  fact  that 
the  present  system  of  cavity  preparation  involves  the  formation  of 
angles  at  different  points  in  the  depths  of  cavities,  it  may  be  well  to 
consider  this  matter  at  this  time. 

If  we  stop  to  study  the  causes  of  fractured  walls,  we  shall  see 
that  they  are  due  either  to  the  fact  that  the  walls  have  been  left 
improtected  by  gold,  or  that  the  gold  has  so  shifted  from  its  orig- 
inal position  in  the  cavity  as  to  bring  undue  stress  upon  the  wall. 
If  we  protect  the  wall  with  gold  and  the  gold  remains  firm,  there 
will  be  no  fracture.  The  question  arises  how  to  maintain  the  gold 
secure  against  movement.  According  to  the  most  approved  and 
logical  mechanical  principles,  this  is  best  solved  by  building  it 
against  flat  walls  joined  by  angles,  rather  than  against  circular 
walls  joined  by  curves.  Other  things  being  equal,  gold  will  shift 
imder  stress  just  in  proportion  as  the  base  upon  which  it  rests  is 
rounded.  It  is  simply  the  difference  between  attempting  to  roll 
£i  cube  and  a  sphere. 

But  aside  from  this,  those  who  have  been  led  to  fear  fractured 
walls  on  account  of  making  angles  in  cavities  need  not  hesitate 
on  this  score,  because  in  the  mouth  it  will  be  found  practically  im- 
possible to  form  an  angle  so  sharp  or  so  acute  that  it  will  determine 
the  location  of  a  fracture, — even  if  a  fracture  should  occur.     The 


CLASSITICATIOlSr    AND    PREPARATION    OF    CAVITIES.  99 

attempt  to  make  angles  insures  more  fully  the  general  plan  of  flat 
surfaces,  and  is  recommended  mainly  for  that  purpose.  It  is 
firmly  believed  that  the  ideal  cavity  should  have  flat  walls  joined 
by  definite  angles,  forming  a  mortise  for  the  filling-material,  but  it 
is  exceedingly  difficult  to  attain  the  ideal  in  the  mouth. 

As  has  already  been  stated,  these  angles  should  be  confined  to 
the  interior  of  the  cavity,  and  when  the  exposed  outlines  are 
formed  they  should  be  given  symmetrical  curves  for  esthetic  rea- 
sons. In  accord  with  this  the  margin  of  the  labial  wall  of  the 
cavities  under  consideration  should  execute  a  short  curve  from  the 
proximal  to  the  incisal  rather  than  have  an  abrupt  angle  at  that 
point.     (Fig.  47.) 

The  lingual  ivall. — This  wall  should  be  cut  freely  away  in  the 
incisal  region  to  admit  of  sufficient  bulk  of  gold  to  represent  con- 
siderable strength  to  the  filling  as  the  proximal  joins  the  incisal 
portion.  This  is  essentially  the  weak  point  of  these  fillings,  any 
breaking  or  stretching  of  the  gold  resulting  in  a  lifting  away  of  the 
proximal  portion  of  the  filling. 

This  wall  should  be  given  some  retentive  form  to  maintain  the 
filling  against  possible  force  from  the  labial  aspect  in  the  form  of 
accidental  blows.  This  can  usually  be  accomplished  in  the  gingi- 
val third  of  the  wall  and  at  the  extremity  of  the  step  if  no  other 
opportunity  presents  itself.     (Fig.  43,  a,  h.) 

The  step. — The  length  of  the  step  mesio-distally  must  be  deter- 
mined by  the  requirements  of  the  case.  It  should  be  extended  far 
enough  to  firmly  anchor  the  filling,  and  in  those  cases  where  the 
incisal  edge  of  the  enamel  has  been  worn  down  so  as  to  expose  the 
dentine  the  step  should  be  carried  across  the  tooth  to  include  all 
exposed  dentine.  It  should  be  made  sufficiently  deep  pulpally  to 
admit  of  strength  to  the  gold,  but  not  far  enough  to  endanger  the 
pulp.  Its  width  labio-lingually  must  be  governed  somewhat  by 
the  thickness  of  the  tooth,  and  in  those  cases  where  necessary  the 
lingual  plate  may  be  cut  away  freely  to  add  to  the  width  of  the 

step. 

The  base  of  the  step,  or  pulpal  wall,  should  be  made  perfectly 
flat.     This  is  one  of  the  most  important  considerations  in  the  kind 


100  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

of  cavity  formation  under  discussion.  If  the  pulpal  wall  is  rounded 
in  the  least  degree,  it  materially  lessens  the  stability  of  the  mesial 
portion  of  the  filling.  The  limited  area  presented  for  the  re- 
ception of  the  gold  at  this  point  imposes  upon  us  the  necessity  for 
maintaining  the  greatest  possible  security  to  a  given  bulk  of  ma- 
terial, and  this  can  only  be  done  by  building  the  gold  against 
a  perfectly  flat  surface.  This  wall  should  also  be  extended  slightly 
into  the  dentine  pulpally  as  it  approaches  the  termination  of  the 
step.  (Fig.  43,  a.)  This  is  to  add  to  the  security  of  the  filling 
against  the  tipping  stress.  As  the  step  terminates,  it  should  end  in 
an  abrupt  wall  parallel  with  the  long  axis  of  the  tooth  and  at  a 
right  angle  with  the  pulpal  wall. 

Fig.  47.  Fig.  48.  Fig.  49.  Fig.  50. 


Technique. — The  same  general  plan  of  technique  may  be  fol- 
lowed as  was  advocated  for  simple  proximal  cavities  up  to  the  for- 
mation of  the  step.  To  form  the  step  an  inverted  cone  bur  should 
be  placed  with  its  side  against  the  incisal  third  of  the  axial  wall,  as 
illustrated  in  Tig.  48,  and  carried  laterally  into  the  tissue  to  the 
extent  required  for  the  length  of  the  step, —  the  cutting  being  done 
with  the  side  of  the  bur.  This  leaves  the  desired  flat  base  to  the 
step.  The  projecting  lingual  plate  of  enamel  left  by  the  bur  can 
readily  be  broken  down  with  chisels. 

The  labial  and  lingual  enamel-margins  can  best  be  beveled  with 
small  sand-paper  disks  in  the  engine,  provided  the  operator  studies 
carefully  their  proper  use.  The  disk  must  be  held  at  such  an  angle 
as  to  give  a  distinct  bevel.  Any  rocking  or  tipping  of  the  disk  will 
result  in  a  rounding  of  the  peripheral  enamel-margin,  the  disad- 
vantage of  which  has  already  been  mentioned.  The  enamel  at 
the  termination  of  the  step  can  be  beveled  with  a  round  bur. 


CLASSIFICATION    AND    PREPAEATION    OF    CAVITIES.  101 

General  Considerations. 

Two  items  of  detail  must  be  carefully  observed  to  make  this 
method  of  cavity  preparation  of  the  highest  esthetic  value.  The 
labial  wall  must  be  left  as  thick  as  possible  to  avoid  the  reflection  of 
the  gold  through  the  enamel,  and  the  gold  must  be  adapted  accu- 
rately to  this  wall  throughout.  If  there  is  any  failure  of  perfect 
adaptation,  the  filling  will  eventually  leak  at  this  point,  giving  rise 
to  an  unsightly  discoloration  under  the  enamel.  The  most  delicate 
and  precise  placing  of  the  gold  and  the  highest  degree  of  density 
possible  are  necessary  for  perfect  results.  When  these  are  at- 
tained, it  is  confidently  believed  that  this  method  will  prove  very 
serviceable  in  a  certain  class  of  cases  which  have  in  the  past  been 
troublesome  to  many  operators. 

The  contraindications  to  this  method  relate  to  cases  where  the 
lingual  wall  has  been  extensively  disintegrated  by  caries,  thus  de- 
stroying the  possibility  of  making  a  step  anchorage.  Usually  such 
cases  involve  the  pulp,  and  wherever  the  pulp  is  removed,  an- 
chorage may  be  obtained  if  necessary  by  cementing  a  strong  iridio- 
platinum  post  into  the  pulp-chamber  and  allowing  it  to  extend 
toward  the  incisal  portion  of  the  cavity  in  such  a  manner  that  the 
gold  can  be  built  around  it  and  the  filling  retained  in  position. 
(Fig.  49.)  Xo  one  method  is  universally  applicable  to  these  cases 
any  more  than  to  other  cavities,  and  the  operator  who  would  at- 
tain the  best  results  must  carefully  study  each  case  that  presents 
and  be  prepared  to  apply  the  particular  method  indicated  in 
that  especial  case.  The  most  that  can  be  taught  are  principles 
and  plans,  and  he  who  cannot  apply  his  individual  ingenuity  to 
meet  the  requirements  of  special  cases  ought  never  to  have  been  a 
dentist. 

The  question  may  arise  with  some  as  to  the  advisability  of  in- 
serting these  large  contour  fillings  instead  of  crowning  the  teeth; 
in  fact,  we  see  occasional  doubts  thrown  upon  contour  operations 
since  crown-work  has  become  so  common.  It  must  always  remain 
a  matter  of  the  nicest  discrimination  just  when  to  abandon  filling 
and  substitute  crowning,  but  it  may  be  laid  down  as  a  safe  axiom 
that  a  tooth  presenting  sufficient  material  to  maintain  a  filling  for  a 


102  PRINGIPLES    AND    PKACTICE    OF    TILLING    TEETH. 

reasonable  period  should  be  filled.  Sometimes  these  extensive 
operations  will  last  many  years,  and  when  the  final  crash  comes 
and  the  filling  is  lost,  the  tooth  presents  the  same  opportunities  for 
cro^uming  that  it  did  before  it  was  filled.  Crown-work  has  not  yet 
been  sufficiently  long  in  use  to  determine  definitely  its  perma- 
nence, and  until  we  have  had  a  more  prolonged  experience  it  may 
be  safe  to  assume  that  in  filling  a  doubtful  tooth  we  extend  the 
serviceability  of  that  tooth  just  the  number  of  years  the  filling  lasts. 
In  other  words,  the  crown  is  likely  to  remain  in  service  as  many 
years  after  the  filling  has  failed  as  it  would  have  done  had  it  been 
employed  in  the  first  instance.  It  is  therefore  sometimes  advisable 
to  fill  these  incisors,  even  when  both  mesial  and  distal  incisal 
angles  are  gone,  and  to  produce  a  filling  such  as  is  illustrated  in 
Fig.  50,  a,  labial  aspect,  h,  lingual  aspect. 

The  objections  often  urged  against  these  extensive  fillings  on 
the  ground  of  their  excessive  weariness  and  nervous  tax  to  the 
patient  are  rapidly  being  discounted  by  modern  methods  of  oper- 
ating, and  the  dental  chair  of  to-day  need  not  be  the  rack  of  torture 
that  it  sometimes  in  the  past  has  been  accounted.  Filling-opera- 
tions by  virtue  of  improved  technique  and  systematic  plans  of  pro- 
cedure have  been  shortened  nearly  one-half  over  former  days. 

Proximal  Cavities  in  Bicuspids  and  Molars. 

The  principles  involved  in  the  treatment  of  caries  occurring  in 
the  proximal  surfaces  of  bicuspids  are  so  similar  to  those  occur- 
ring in  like  surfaces  of  molars  that  they  will  be  considered  as  one 
class  of  cavities.  Minor  differences  in  the  detail  of  the  work  will, 
it  is  true,  be  called  for,  but  these  are  readily  suggested  by  the 
differences  in  the  forms  of  the  teeth.  The  position  and  function 
of  bicuspids  and  molars  are  nearly  identical,  and  they  are  subject 
to  practically  the  same  influences  leading  to  decay  primarily  and 
to  a  recurrence  of  decay  around  fillings.  The  same  forces  are  at 
work  to  dislodge  fillings,  and  the  same  general  plan  of  anchorage 
must  be  pursued  in  the  one  as  in  the  other.  For  these  reasons 
they  are  treated  in  common. 


CLASSIFICATIOX    AND    PREPARATION    OF    CAVITIES.  103 

Simple  Proximal  Cavities  not  Involving  Other  Surfaces. 

The  instances  are  very  rare  where  it  may  be  deemed  advisable 
to  fill  this  kind  of  a  cavity.     Usually  when  decay  begins  on  the 
proximal  surface  of  a  bicuspid  or  molar,  the  proper  preparation 
of  the  cavity  involves  its  extension  through  to  the  occlusal  surface. 
Almost  the'  only  exceptions  relate  to  those  cases  where  the  cavity 
faces  an  open  space  caused  by  the  loss  of  a  tooth,  or  to  those  occa- 
sional instances  where  there  has  been  extensive  recession  of  the 
eums  in  the  interproximal  space  and  consequent  decay  in  the 
gingival  region.     This  latter  usually  occurs  in  advanced  age,  when 
such  extensive  cutting  as  would  be  necessary  to  involve  the  oc- 
clusal surface  would  not  be  justifiable,  and  where  the  open  inter- 
proximal space  admits  of  access  from  the  buccal  aspect.     The 
farther  rootwise  the  decay  occurs  the  stronger  the  argument  for 
filling  without  extending  occlusally,   on  account  of  the  better 
facility  for  approach  and  the  greater  thickness  of  the  occlusal  wall. 
But  in  ordinary  caries  occurring  near  the  contact  point,  and 
with  the  teeth  standing  in  line  one  against  the  other,  the  rule 
should  be  to  open  the  cavity  to  the  occlusal  surface.     The  reasons 
for  this  lie  in  the  fact  that  in  such  cases  access  cannot  be  gamed  to 
do  perfect  work  short  of  very  extensive  separation,  and  then  when 
the  teeth  have  been  so  separated  and  filled,  and  have  fallen  back 
to  their  original  position,  an  element  of  danger  to  the  filling  re- 
mains on  account  of  the  margin  of  the  filling  being  too  near  the 
contact  point.     The  reason  that  decay  begins  in  this  locality  m  the 
first  instance  is  because  a  certain  area  of  the  tooth-substance  is  left 
exposed  to  the  action  of  micro-organisms,  undisturbed  by  friction 
of  the  tongue,  cheeks,  the  tooth-brush,  or  of  food  in  the  process  of 
mastication.     If  the  line  between  enamel  and  filling  be  left  near 
the  contact  point,  the  same  influences  which  induced  the  original 
decav  mav  be  expected  to  act  on  the  enamel  at  the  margin  of  the 
filling  to  bring  about  a  recurrence.     If  the  cavity  is  extended  oc- 
.-Insally  far  enough  to  make  a  clean  margin,  the  occlusal  wall  is 
thereby  rendered  too  weak  to  withstand  mastication.     All  opera- 
tions performed  upon  these  surfaces  without  extension  must  there- 
fore be  considered  in  the  light  of  temporary  work. 


104:  PKIIfCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

Sometimes  such  fillings  do  good  service  through  the  care  with 
which  they  are  inserted,  coupled  with  the  probable  fact  that  just 
at  this  time  the  patient  acquires  a  partial  or  complete  immunity 
from  caries.  Many  indifferent  operations  have  received  credit  for 
being  perfect  owing  to  this  very  fact  of  immunity,  and,  as  has  al- 
ready been  intimated,  the  whole  question  of  periodical  immunity 
and  susceptibility  of  our  patients  in  regard  to  the  attack  or  progress 
of  dental  caries  should  receive  more  careful  consideration  than  it 
does.  But  what  concerns  us  now  in  treating  the  present  subject  is 
that  clinical  experience  proves  most  of  these  small  fillings  to  be 
temporary,  and  resort  should  be  had  to  their  occasional  insertion 
with  this  fact  clearly  in  mind. 

The  plan  of  anchorage  for  such  fillings  is  very  simple.  There 
is  little  stress  to  dislodge  the  filling,  and  all  that  seems  necessary 
in  the  formation  of  the  cavity  is  to  make  parallel  walls  surrounding 
it  at  right  angles  with  the  axial  wall,  and  to  bevel  the  enamel-mar- 
gins. 

Proximo-Occlusal  Cavities  in  Bicuspids  and  Molars. 

Wherever  decay  has  so  invaded  the  proximal  surface  as  to  in- 
volve the  occlusal  surface,  or  wherever  it  is  deemed  necessary  to 
open  the  cavity  to  the  occlusal  surface  in  those  cases  presenting 
with  this  wall  still  remaining,  a  new  class  of  conditions  confronts 
the  operator.  In  view  of  the  fact,  as  already  intimated,  that  most 
proximal  cavities  in  these  teeth  must  be  made  to  include  the  oc- 
clusal surface,  it  becomes  necessary  to  study  somewhat  carefully 
the  conditions  governing  the  treatment  of  such  cases. 

The  principal  objects  to  be  attained  in  the  insertion  of  this 
kind  of  a  filling  are,  first,  to  check  the  existing  decay;  second,  to 
prevent,  so  far  as  possible,  a  recurrence  of  decay  in  the  future; 
third,  to  securely  anchor  the  filling  against  displacement  from  the 
stress  of  mastication;  and,  fourth,  to  so  restore  the  original  form  of 
the  tooth  that  it  will  be  maintained  in  its  proper  relation  with  the 
other  teeth  and  with  the  gum-tissue  filling  the  interproximal  space. 

The  first  of  these  requirements  may  be  met  by  simply  removing 
the  decay  and  inserting  a  filling  with  perfect  margins;  and  this 
would  seem  to  be  the  limit  of  attainment  with  many  operators. 


CLASSIFICATION    AXD    PEEPAKATIOX    OF    CAVITIES.  105 

A  failure  to  recognize  other  necessities  in  the  case  is  accountable 
for  much  of  the  disappointment  following  these  operations, 
through  the  temporary  nature  of  such  a  line  of  work. 

The  same  general  rules  of  extension  for  prevention  apply  to 
these  cavities  that  were  given  for  proximal  cavities  in  the  an- 
terior teeth,  except  that  in  bicuspids  and  molars  esthetic  con- 
siderations do  not  so  materially  affect  the  case,  and  the  rules  may 
therefore  be  less  frequently  waived  on  this  account.  The  usual 
points  of  recurrence  of  decay  around  these  fillings  are  at  the 
gingivo-buccal  and  gingivo-lingual  angles  of  the  cavity,  though  in 
cavities  left  very  narrow  bucco-lingually  the  entire  buccal  and 
lingual  margins  may  become  involved. 

Another  form  of  failure,  where  cavities  are  narrow  in  the  region 
of  the  marginal  ridge,  relates  to  a  fracture  of  the  enamel  at  the 
proximo-occlusal  angles.  Enamel  left  in  this  form  is  easily  broken 
down  by  the  stress  of  mastication,  causing  a  break  between  the 
filling  and  the  margin.  Fig.  51  illustrates  a  bicuspid  with  a  nar- 
row filling  a,  points  of  recurrence  of  decay  h  h,  and  of  fractured 
enamel  c  c.  The  line  d  indicates  extension  to  avoid  these  forms  of 
failure. 

The  plan  of  anchorage  for  these  fillings  calls  for  careful  con- 
sideration along  the  lines  of  the  most  approved  mechanical  princi- 
ples, and  with  a  due  regard  for  the  location  of  the  filling  and  the 
probable  stress  to  which  it  will  be  subjected  in  the  process  of  mas- 
tication. The  force  of  mastication  varies  greatly  in  different 
individuals,  and  the  intelligent  operator  will  take  cognizance  of  this 
and  govern  his  operations  thereby. 

In  estimating  the  probable  durability  of  a  filling  and  the  extent 
of  anchorage  required  to  maintain  it  in  place,  a  careful  study 
should  be  made  of  the  landmarks  of  mastication  in  the  mouth  un- 
der treatment.  The  expression  "landmarks  of  mastication"  is 
coined  for  the  purpose  of  directing  attention  to  this  form  of  study. 
Mastication  leaves  its  marks  plainly  and  indelibly  upon  the  teeth 
and  upon  fillings  placed  in  them,  and  these  markings  offer  a  good 
index  for  the  observant  operator  to  estimate  the  probable  average 
force  exerted  in  ordinary  mastication  in  a  given  mouth.     The  use 


106  PRINCIPLES    AND    PEACTICE    OF    FILLING    TEETH. 

of  the  gnathodynamometer  for  the  purpose  of  recording  the  stress 
of  mastication,  while  very  valuable  for  scientific  study  and  for 
throwing  much  light  on  the  possible  force  of  mastication,  is  not 
considered  to  be  the  most  reliable  index  to  the  force  actually  em- 
ployed in  the  comminution  of  food.  The  greatest  possible  force 
that  can  be  exerted  in  closing  the  jaAvs  is  often  far  removed  from 
the  actual  force  used  in  mastication  in  the  same  mouth,  and  is 
not  invariably  relative  to  it.  For  this  reason,  if  we  accept  it  as 
our  sole  guide  for  the  extent  of  anchorage  required  for  our  fill- 
ings, we  shall  in  some  instances  subject  our  patients  to  unneces- 
sarily broad  and  painful  cutting  to  accomplish  an  object  which 
might  have  been  attained  by  less  heroic  means.  On  the  other 
hand,  we  may  sometimes  fall  short  of  adequate  anchorage  in 
those  cases  where  the  gnathodynamometer  gives  a  low  record,  but 
where  the  actual  wear  and  tear  on  fillings  in  mastication  is  some- 
what severe. 

,  It  is  true  we  should  aim  in  all  cases  to  anchor  our  fillings  in 
such  security  that  the  greatest  possible  stress  of  which  the  jaws  are 
capable  will  not  dislodge  them,  but  the  conditions  under  which  we 
are  compelled  to  operate  "will  not  invariably  permit  it.  The 
requisite  bulk  of  tooth-tissue  is  not  always  left  for  us  by  the  carious 
process,  and  the  sensibilities  of  our  patient  must  also  be  considered. 
The  same  statement  is  true  here  which  was  used  in  connection  with 
cutting  cavities  in  anterior  teeth,  that  we  must  not  jeopardize  the 
nervous  system  of  our  patient  to  follow  out  some  heroic  theory. 
The  fact  of  ignoring  the  patient  in  these  matters  by  a  blind  pursuit 
of  an  ideal  in  the  mind  of  the  operator  is  accountable  for  much  of 
the  aversion  experienced  against  the  dental  chair,  and  we  must 
have  a  care  not  to  discourage  people  against  permitting  dental 
service  to  be  done  for  them  by  too  great  a  degree  of  severity  during 
the  operation.  This  does  not  imply  that  we  must  be  slip-shod  in 
our  methods,  or  that  we  must  at  all  times  avoid  giving  pain.  It 
is  occasionally  necessary  to  give  pain,  but  the  operator  should  care- 
fully study  his  patient  and  limit  the  discomfort  to  a  reasonable  de- 
gree of  tolerance.  (This  matter  will  be  considered  more  in  detail 
in  a  subsequent  chapter  on  the  treatment  of  sensitive  dentine.) 


CLASSIFICATIOX    AXD    PEEPAKATIOX    OF    CAVITIES 


107 


The  landmarks  of  mastication  relate  to  worn  surfaces  of  enamel 
at  points  of  occlusal  contact  which  are  evidently  formed  bv  me- 
chanical wear  instead  of  by  erosion,  to  deep  indentations  in  fillings 
made  by  repeated  and  vigorous  thrusts  of  the  opposing  cusp,  and 
occasionally  to  fractured  and  jagged  enamel  showing  evidence 
of  rough  usage.  If  the  operator  will  give  a  careful  study  to  the 
condition  of  his  patients'  teeth  and  watch  for  these  markings  he 
will  soon  be  able  to  tell  quite  accurately  the  probable  degree 
of  service  which  a  given  set  of  teeth  are  called  upon  to  do  at  table, 
and  it  will  often  guide  him  in  his  methods  of  anchoring  fillings. 

The  different  plans  of  anchorage  for  these  proximo-occlusal 
fillings  in  bicuspids  and  molars  deserve  careful  consideration.    The 


Fig.  51. 


Fig.  52. 


Fig.  53. 


-^-5 


method  almost  universally  employed  in  the  past  has  been  to  cut 
a  groove  along  the  buccal  and  lingual  walls  of  the  cavity,  and  in 
some  instances  to  groove  the  gingival  wall.  The  limitations  of  this 
method  relate  to  the  insecurity  of  such  anchorage  against  heavy 
stress,  and  to  the  danger  of  weakening  the  walls,  particularly  in 
those  cases  where  the  buccal  and  lingual  outlines  of  the  cavity  are 
sufficiently  extended  for  safety  against  recurrence  of  decay. 
Unless  the  grooves  are  very  broad  and  deep — a  condition  disas- 
trous to  cavity-walLs — any  tipping  stress  on  such  a  filling  will  tend 
to  lift  it  slightly  away  from  the  axial  wall,  leaving  a  leak  along  the 
filling  at  that  point.  Then,  again,  the  occlusal  aspect  of  this  form 
of  filling  is  ordinarily  unsatisfactory.  In  bicuspids  especially  the 
filling  encounters  a  fissure  running  mesio-distally  between  the 
cusps,  and  leaving  at  the  junction  of  the  filling  and  fissure  a 
shoulder  on  the  filling  impossible  of  perfect  finish,  and  an  element 


108  peijstciples  and  practice  of  filling  teeth. 

of  weakness  in  the  probable  recurrence  of  decay  along  the  fissnre. 
As  has  already  been  stated,  a  fissure  is  invariably  a  defect  in  the 
tooth  whereby  two  islands  of  calcification  have  failed  to  coalesce 
in  its  development,  leaving  a  break  in  the  continuity  of  the  enamel 
at  that  point  and  a  crevice  for  the  ingress  of  deleterious  matter. 
It  should  therefore  be  the  constant  rule  that  whenever  a  cavity  on 
the  occlusal  surface  of  a  tooth  encounters  a  fissure,  the  fissure 
should  be  drilled  out  to  its  extreme  end  and  included  in  the  cavity. 

What  would  appear  to  be  a  much  preferable  method  of  anchor- 
age to  that  just  considered,  and  one  offering  greater  security  to  the 
filling,  is  to  create  a  step  on  the  occlusal  surface  of  the  tooth  at 
right  angles  with  the  proximal  portion  of  the  cavity,  and  extend- 
ing sufficiently  into  the  occlusal  surface  to  effectively  lock  the 
filling  into  place.  This  also  results  in  the  obliteration  of  the  fis- 
sure and  the  formation  of  a  filling  easy  of  finish.  Fig.  52  shows 
the  occlusal  surface  of  a  bicuspid  with  the  original  cavity  a, — the 
form  left  by  many  operators, — h  the  fissure,  and  c  the  line  of 
extension. 

With  this  form  of  anchorage  the  filling  cannot  be  displaced 
short  of  a  fracture  of  the  filling  or  a  stretching  of  the  material  at 
the  point  where  the  proximal  portion  joins  the  occlusal,  through 
repeated  impacts  of  the  opposing  cusp  in  mastication.  To  prevent 
this  the  cavity  should  be  made  deep  enough  at  this  point  to  allow 
of  sufficient  bulk  of  filling-material  for  strength,  and  the  material 
should  be  thoroughly  packed  and  well  condensed  to  give  it  the 
greatest  degree  of  resisting  power. 

Another  point  in  connection  with  the  dislodgment  of  these  fill- 
ings relates  to  the  form  of  the  occlusal  surface  of  the  filling  and 
also  the  form  of  the  cusps  on  the  opposing  teeth.  While  the 
general  rule  holds  good  that  in  the  formation  of  fillings  they  should 
be  made  as  nearly  as  possible  to  reproduce  the  original  form  of  the 
tooth,  yet  in  these  proximo-occlusal  fillings  a  slight  modification 
of  the  original  form  is  often  advisable.  In  the  natural  form  we 
find  the  marginal  ridge  of  enamel  standing  more  prominent  than 
the  enamel  between  the  cusps,  thereby  receiving  greater  impact  in 
the  process  of  mastication.     If  in  the  insertion  of  the  filling  we 


CLASSIFICATION    AND    PKEPARATION     OF    CAVITIES.  10£^ 

reproduce  the  marginal  ridge,  we  subject  the  filling  to  too  great 
leverage  at  a  point  where  it  has  a  tendency  to  tip  away  from  its 
anchorages.  This  may  be  avoided  by  making  the  filling  as  high 
as  possible  midway  between  the  cusps,  and  sloping  it  toward  the 
contact  point  in  such  a  way  as  to  avoid  making  a  marginal  ridge 
and  to  present  a  gradual  incline  from  the  highest  point  between 
the  cusps  to  the  point  of  contact  on  the  proximal  surface.  In 
doing  this  the  occlusal  surface  of  the  filling  is  so  presented  to  the 
cusp  of  the  opposing  tooth  that  the  tendency  on  closure  of  the  jaws 
is  to  force  the  filling  laterally  into  the  cavity  against  the  axial  wall 
instead  of  lifting  it  away,  as  would  result  if  the  marginal  ridge 
were  reproduced.  Fig.  53  a  shows  the  section  of  a  bicuspid  mesio- 
distally  with  filling  in  place  and  the  marginal  ridge  reproduced. 
The  CUS13  of  the  opposing  tooth  would  tend  to  tip  the  filling  in  the 
direction  indicated  by  the  arrow.  Fig.  53  &  shows  sloping  filling 
with  the  direction  of  force  diverted  against  the  interior  of  the 
cavity. 

This  plan  does  not  materially  impair  the  efiiciency  of  the  tooth 
for  mastication,  but  even  if  it  did  lessen  the  masticating  area  some- 
what it  would  still  be  justifiable  on  the  ground  that  a  tooth 'with 
its  masticating  area  reduced  one-half,  but  containing  a  filling  safely 
anchored  and  enamel  so  sloped  as  to  avoid  fracture,  is  more  valu- 
able than  one  presenting  a  full  masticating  area  subject  to  the 
danger  of  filling  displacement  and  fractured  enamel-walls.  This 
does  not  imply  that  the  filling  should  be  made  narrower  mesio- 
distally  at  the  contact  point  than  the  tooth  originally  was.  For 
reasons  which  will  appear  later  the  full  width  of  the  tooth  must  be 
maintained  wherever  possible.  This  may  result  in  some  instances 
in  the  point  of  contact  with  the  proximating  tooth  being  carried 
slightly  rootwise  of  the  original  contact,  but  if  care  is  exercised 
this  may  safely  be  done  without  impairing  the  efiiciency  of  the 
contact  or  interfering  with  the  gum-tissue  in  the  interproximal 
space. 

The  treatment  of  the  cusps  of  opposing  teeth  coming  against 
these  fillings  is  a  matter  of  much  importance,  particularly  with 
bicuspids.     When   the   sharp  Imccal   cusp   of   a  lower   bicuspid 


110  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

impinges  so  far  into  a  cavity  on  the  opposing  upper  bicuspid  as  to 
necessitate  making  the  filling  too  thin  for  strength,  or  where  it 
passes  so  far  between  the  cusps  of  the  upper  tooth  as  to  form  a 
wedge  capable  of  splitting  the  tooth,  the  tip  of  the  cusp  on  the 
lower  bicuspid  should  be  ground  down  so  as  to  shorten  it  and 
present  a  broad  surface  to  the  upper  tooth  instead  of  a  wedge 
shape.  This  will  result  in  the  formation  of  a  thicker  and  stronger 
filling  in  the  decayed  tooth,  and  such  a  change  in  the  direction  of 
force  exerted  by  the  lower  tooth  as  to  minimize  the  danger  of 
splitting  its  opponent.  With  a  wedge-shaped  cusp  there  is  much 
lateral  force  exerted  buccally  and  lingually  against  the  cusps  of  the 
upper  tooth,  but  with  a  broad,  flattened  cusp  the  direction  of  force 
is  more  nearly  parallel  with  the  long  axis  of  the  tooth  and  the 
tendency  to  split  is  lessened.  This  grinding,  if  done  judiciously, 
will  not  interfere  with  the  usefulness  nor  impair  the  integrity  of 
the  lower  bicuspid.  The  enamel  is  very  thick  at  that  point, 
and  there  is  little  liability  to  decay,  so  that  this  method  should 
be  employed  quite  frequently  for  the  greater  permanence  of  our 
fillings  and  the  greater  safety  of  the  teeth,  especially  in  those 
cases'  where  the  cusps  of  the  lower  teeth  are  very  prominent  and 
sharp. 

One  of  the  most  important  considerations  in  the  management 
of  these  proximo-occlusal  cavities  relates  to  the  form  of  the  filling 
on  the  proximal  surface.  It  should  be  so  built  out  to  a  contour 
that  the  tooth  will  be  maintained  in  its  proper  position  in  the  arch, 
and  that  the  gum-tissue  in  the  interproximal  space  shall  be  pro- 
tected and  preserved  in  a  healthy  condition.  When  the  teeth  stand 
in  their  normal  relation  in  the  jaws  they  are  supported  on  their 
proximal  surfaces  by  contact  with  the  tooth  next  in  line,  and  the 
interproximal  space  between  these  points  of  contact  and  the  border 
of  the  alveolar  process  is  filled  with  gum-tissue.  This  gum-tissue 
has  an  arched  form  bucco-lingually,  vnth  the  crest  of  the  arch  near 
the  contact  point;  and  this  form  facilitates  the  cleansing  of  the 
space  by  a  deflection  of  the  food  buccally  and  lingually  in  mastica- 
tion. So  long  as  the  contact  points  are  small  and  the  space  of 
normal  form  and  filled  with  gum-tissue,  foreign  material  will  not 


CLASSIFICATIOISr    AND    PREPARATION    OF    CAVITIES.  Ill 

find  a  lodgmeut  in  the  space.  In  the  comminution  of  fibrous 
food,  such  as  meat,  the  fibers  may  occasionally  be  forced  between 
the  contact  points,  but  they  are  not  retained  there  on  account  of 
the  narrowness  of  contact.  The  next  passage  of  food  on  closure  of 
the  jaws  in  being  squeezed  out  buccally  and  lingually  along  the 
incline  of  gum  will  catch  them  and  carry  them  with  it,  leaving  the 
space  clean. 

When  decay  takes  place  on  the  proximal  surface  and  the  con- 
tact point  breaks  down,  the  teeth,  lacking  proximal  support,  have 
a  tendency  to  drop  together,  forcing  the  gum  from  between  them 
and  narrowing  the  space.  In  cases  of  extensive  caries  the  teeth 
may  so  change  their  position  as  to  practically  obliterate  the  space 

FiQ.  54.  Fig.  55.  Fig.  56.  Fig.  57. 


and  crush  out  all  of  the  gum-tissue,  leaving  the  buccal  and  lingual 
festoons  of  the  gum  more  prominent  than  that  portion  midway 
between  the  teeth.  This  results  in  an  inverted  arch  to  the  gum, 
and  produces  a  pocket  between  the  teeth  which  is  especially  favor- 
able to  the  reception  and  retention  of  food  debris.  Fig.  54  illus- 
trates the  proximal  surface  of  a  sound  lower  molar  with  the  gum 
covering  it  in  a  normal  arched  form;  Fig.  55,  a  similar  case, 
with  proximal  decay  and  an  inverted  arch  to  the  gum,  forming 
a  pocket.  When  caries  occurs  in  this  way  the  necessary  pro- 
cedure to  restore  the  gum  to  health  is  to  wedge  the  teeth  apart  to 
their  original  position,  and  then  to  so  contour  the  filling  that  they 
will  be  maintained  there. 

If  the  filling  is  inserted  without  this  precaution  the  result  is  a 
broad,  flat  proximal  surface  to  the  filling,  which  will  catch  fibers 
of  food  and  retain  them  to  decompose.  This  wedging  of  food 
between  teeth  is  an  element  of  great  discomfort  to  the  patient, 
and  a  prolific  source  of  failure  in  these  proximal  fillings.  It  not 
only  results  in  recurrence  of  decay,  but  sadly  impairs  the  health  of 


112  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

the  gum  and  pericemental  membrane.  'No  operation  should  be 
considered  satisfactory  which  does  not  include  in  its  performance  a 
due  regard  for  the  form  of  the  interproximal  space  and  the  health 
of  the  gum-tissue  within  it. 

The  attempt  to  prevent  food  from  wedging  between  teeth  by 
making  broad  contacts  built  tightly  against  the  proximating  tooth 
usually  fails  in  its  object  through  the  fact  that  contact  cannot 
in  this  way  be  made  so  perfect  that  at  times  the  individual  move- 
ment of  the  teeth  one  against  the  other  will  not  result  in  the 
passage  of  fibrous  food  between  them.  When  it  once  makes  its 
way  between  the  filling  and  the  proximating  tooth,  it  is  firmly 
held  there  by  the  broad  contact.  The  only  safe  form  to  give  these 
fillings  is  to  make  a  narrow  rounded  contact,  sufiiciently  dense  to 

Fig.  58.  Fig.  59. 


maintain  the  teeth  in  position  and  to  preserve  its  form  against  the 
wear  occasioned  by  the  individual  movement  of  the  teeth.  This 
wear  is  sometimes  quite  severe,  as  is  shown  by  the  facets  worn  in 
the  enamel  on  the  proximal  surfaces  of  many  sound  teeth.  This 
recalls  the  fact  that  these  worn  facets  are  often  a  prolific  source  of 
discomfort  to  the  patient,  even  where  there  is  no  decay;  and  in 
those  cases  where  a  filling  is  being  built  in  a  cavity  proximating 
a  tooth  with  an  extensive  facet,  the  margins  of  the  facet  should  be 
slightly  rounded  ofi;  to  produce  an  oval  form  to  the  surface.  The 
attention  of  the  operator  should  not  be  limited  to  the  single  tooth 
being  filled,  but  he  should  study  carefully  the  adjacent  parts,  to  the 
end  that  the  teeth  and  gums  in  the  entire  region  be  placed  in  the 
best  possible  condition. 

Fig.  56  shows  the  buccal  surfaces  of  two  lower  bicuspids  and  the 
first  molar.  There  is  no  decay  between  the  bicuspids,  and  the 
contact  is  normal  and  gum  healthy.  Between  the  second  bicuspid 
and  first  molar  decay  has  taken  place  on  both  proximal  surfaces, 


CLASSIFICATIOX    AND    PKEPAKATION    OF    CAVITIES.  113 

allowing  the  teeth  to  fall  together  and  obliterate  the  space.  The 
congested  buccal  festoon  of  gum  is  shown  opposite  the  original 
position  of  the  space.  Fig.  57  illustrates  the  same  two  teeth  when 
wedged  apart  and  contour  fillings  made  to  reproduce  the  inter- 
proximal space.  The  gum-tissue  is  seen  reoccupying  the  space 
in  a  normal  condition.  Fig.  5S  represents  the  occlusal  aspect  of 
the  case,  with  outline  of  fillings  and  point  of  contact.  Fig.  50 
shows  a  section  mesio-distally  at  the  contact  point. 

In  view  of  the  importance  of  making  contact  points  of  the 
proper  form  and  size  on  all  proximal  fillings,  it  would  seem  neces- 
sary to  study  somewhat  carefully  the  precise  form  and  the  exact 
area  of  contacts  found  in  normally  shaped  sound  teeth.  To  make 
an  ocular  examination  of  the  teeth  in  the  mouth  is  somewhat  mis- 
leading. With  the  teeth  standing  in  line  in  the  arch  and  the 
gums  filling  the  interproximal  spaces,  the  appearance  would  tend 
to  convey  the  impression  that  a  much  larger  area  of  enamel  was 
in  contact  than  is  actually  the  case.  The  presence  of  foreign  ma- 
terial or  even  of  moisture  clinging  to  the  proximal  surfaces  ob- 
scures the  vision  so  that  a  true  estimate  can  never  be  made  by  this 
kind  of  examination.  Neither  will  an  operator  be  likely  to  gain  a 
clear  conception  of  the  area  of  contact  by  an  examination  of  the 
teeth  singly  out  of  the  mouth  unless  in  cases  of  worn  facets,  which 
should  not  be  considered  as  typical  or  normal  contacts.  The 
variation  in  the  breadth  of  the  proximal  surfaces  of  the  different 
teeth  would  seem  to  imply  that  there  must  be  a  like  variation 
in  the  area  of  contact,  but  this  is  by  no  means  the  case. 

The  fact  is  that  the  area  of  enamel  in  actual  contact  even 
between  the  broadest  molars  is  normally  almost  infinitesimal,  and 
the  surest  means  of  determining  this  beyond  any  possibility  of 
doubt  is  to  take  two  such  teeth  that  have  been  extracted,  and, 
placing  them  together  in  the  same  relation  to  each  other  which 
they  sustained  in  the  mouth,  hold  them  up  to  the  light  with  the 
buccal  surfaces  presented  to  the  operator.  It  will  be  seen  at 
what  a  minute  point  the  light  is  obscured  by  contact, — a  point  so 
very  small  as  scarcely  to  admit  of  measurement.  Now  turn  the 
teetli  so  that  the  occlusal  surfaces  are  presented  to  the  operator 

8 


114  PKEsrciPLirs  a^d  pbactice  of  inxr^rG  teeth. 

and  a  similar  result  is  apparent,  or  if  possible  intensified.  TMs 
is  an  object  lesson  in  the  area  of  contact  between  teetb  at  once  so 
apparent  and  sc'  vivid  tliat  the  experiment  should  not  be  ignored 
by  any  dentist  "wbo  is  called  npon  to  fill  cavities  in  these  surfaces. 

This  must  not  imply  that  all  proximal  surfaces  have  the  same 
form,  or  that  the  contact  jwints  are  located  in  the  same  place  on  all 
teeth.  A  close  study  of  the  anatomical  features  of  the  proximal 
surfaces  of  the  <iifferent  teeth  tvlU  reveal  a  great  variation  in  form, 
and  this  variation  should  be  respected  in  the  building  of  fillings. 
For  instance,  a  lower  second  bicuspid  usually  presents  a  proximal 
surface  somewhat  roimded  bucco-lingually  at  the  contact  point, 
and  sloping  away  from  this  point  buccally  and  lingually  with  a 
relatively  equal  degree  of  curvature.  This  brings  the  contact 
point  nearly  midway  between  the  buccal  and  lingual  surfaces,  and 
calls  for  a  generally  roimded  form  to  the  filling.  On  the  contrary, 
the  upper  first  molar  presents  on  its  mesial  aspect  a  greatly  flat- 
tened surface  with  the  contact  point  located  much  nearer  the 
buccal  than  the  lingual  surface,  and  sloping  away  abruptly  toward 
the  buccal  and  gradually  toward  the  lingual.  Speaking  in  a  gen- 
eral way.  it  will  be  foimd  that  in  making  the  contact  point  on 
fillings  the  distinction  should  be  made  between  the  upper  bicuspids 
and  molars  and  the  lower  ones,  that  on  the  former  it  should  be 
located  much  nearer  the  buccal  than  the  lingual  surface,  while 
on  the  latter  it  should  be  more  nearly  midway  between  the  two. 
The  location  of  the  contact  point  occluso-gingivally  is  quite  uni- 
form in  both  jaws,  the  common  rule  being  to  find  it  near  the  oc- 
clusal surface  sloping  abruptly  with  a  sharp  curve  toward  this 
surface  and  falling  away  gradually  toward  the  giagival. 

There  is  often  a  marked  difference  between  the  prominence 
of  the  contact  point  on  the  mesial  and  on  the  distal  surfaces  which 
applies  to  both  the  upper  and  lower  teeth,  the  distal  surfaces 
usually  presenting  a  bolder  and  more  rounded  prominence  than  the 
mesial,  and  therefore  curving  sharply  to  the  gingival.  This  re- 
sults in  stich  a  form  to  the  interproximal  spaces  that  they  incline 
with  their  apices  directed  somewhat  backward,  and  their  mesial 
boundarv  a  trifle  larsrer  than  their  distaL 


CLASSIFICATIOX    AND    PREPAEATION    OF    CAVITIES.  115 

To  gain  the  most  intelligent  idea  of  the  actual  form  of  the  in- 
terproximal spaces  and  the  variations  in  the  proximal  surfaces 
of  the  teeth,  a  close  study  should  be  made  of  a  well-formed  jaw 
from  a  skeleton  with  the  teeth  in  their  normal  position  in  the  arch. 
An  examination  of  such  a  jaw  from  the  buccal,  the  lingual,  and 
the  occlusal  aspects  will  place  the  operator  in  a  more  enlightened 
relation  to  the  subject  than  can  be  attained  in  any  other  way. 

In  judging  the  area  of  contact  between  teeth  in  the  mouth  or 
between  fillings,  the  most  convenient  test  is  the  ligature.  If  a 
ligature  be  passed  between  the  proximal  surfaces  of  teeth  having 
normal  contact  points  it  will  bind  quite  tightly  near  the  occlusal 
surfaces  as  if  meeting  a  sudden  obstruction,  but  this  obstruction 
is  narrow  and  the  ligature  readily  springs  past  it  under  pressure, 
and  moves  back  and  forth  with  the  greatest  freedom  in  the  inter- 
proximal space.  In  lifting  the  ligature  out  of  the  space  it  should 
pass  nearly  to  the  occlusal  surface  before  being  engaged  by  the 
contact  points,  and  should  then  come  out  from  between  the  teeth 
Avith  a  sudden  snap.  If  the  ligature  drags  in  passing  the  con- 
tact points,  or  if  it  is  frayed  against  the  surfaces,  the  contact  is  not 
normal  whether  it  be  on  a  filling  or  on  a  tooth. 

Separating  the  Teeth. 

In  those  cases  where  the  decay  has  not  progressed  very  far 
and  where  there  has  been  little  breaking  down  of  the  contact 
point  and  consequently  no  dropping  together  of  the  teeth,  suf- 
ficient space  may  often  be  obtained  by  the  separator,  the  proper 
use  of  which  has  already  been  indicated.  But  where  any  con- 
siderable movement  of  the  teeth  is  necessary  it  is  more  safely 
and  comfortably  accomplished  by  gradual  wedging.  The  same 
system  may  be  employed  as  was  advocated  for  anterior  teeth,  with 
the  exception  that  a  more  extended  use  may  be  made  of  gutta- 
percha. This  substance,  if  properly  employed,  is  really  the  ideal 
material  for  separating  bicuspids  and  molars,  and  its  more  gen- 
eral use  would  do  much  to  remove  the  prejudice  existing  against 
having  teeth  wedged. 

It  may  be  used   in  the  following  manner:  The  occlusal  wall 


116  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

should  be  broken  down  in  those  cases  where  it  is  still  standing, 
and  the  cavity  cleared  of  debris  and  softened  dentine  with  a  few 
sweeps  of  a  broad  spoon  excavator.  It  should  then  be  flooded 
with  an  essential  oil  and  the  excess  wiped  out,  leaving  the  cavity- 
walls  soaked  in  the  oil.  Gutta-percha  should  then  be  packed  into 
the  cavity  and  snugly  against  the  proximating  tooth,  so  that 
pressure  may  be  exerted  between  this  tooth  and  the  axial  wall  of 
the  cavity.  The  gutta-percha  should  be  built  up  sufficiently  for 
the  cusp  of  the  opposing  tooth  to  impinge  upon  it  in  closing  the 
jaws,  and  the  repeated  impact  thus  resulting  will  tend  to  spread  the 
gutta-percha  and  force  the  teeth  apart.  By  this  method  teeth 
may  be  separated  with  very  little  soreness,  it  being  the  rarest  ex- 
ception for  a  patient  ever  to  complain  of  this  sort  of  wedge.  The 
process  is  somewhat  slow,  but  it  may  be  hastened  in  emergency 
cases  by  first  applying  the  separator  and  lifting  the  teeth  as  far 
apart  as  practicable  before  packing  the  gutta-percha.  Ordinarily 
without  the  use  of  the  separator  the  gutta-percha  may  be  left  in  a 
Aveek,  and  if  at  the  end  of  that  time  there  is  not  sufficient  space, 
fresh  gutta-percha  may  be  added  and  the  case  dismissed  for  another 
week. 

To  economize  time  in  the  management  of  these  cases,  it  is  well 
for  the  operator,  on  examining  a  mouth  where  several  fillings  are 
needed,  to  select  these  proximal  cases  at  the  first  sitting  and 
pack  gutta-percha  in  each  of  them.  He  may  then  proceed  with 
the  other  necessary  work  in  the  mouth,  and  by  the  time  that  is  com- 
pleted some  of  the  teeth  thus  wedged  will  be  found  ready  to  operate 
upon.  The  more  stubborn  cases  may  be  left  till  the  last,  and,  if 
necessary,  the  gutta-percha  may  be  renewed  in  these  as  the  other 
operations  are  under  progress. 

Where  the  cavity  slopes  so  rapidly  from  the  axial  wall  to  the 
gingival  margin  as  to  result  in  a  sliding  of  the  gutta-percha  into 
the  interproximal  space  instead  of  exerting  lateral  pressure,  the 
gingival  wall  should  be  somewhat  flattened  previous  to  inserting 
the  wedge.  The  gutta-percha  will  then  rest  on  a  broad  base  and 
will  spread  under  pressure,  exerting  force  in  the  required  direc- 
tion. 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES.  llT 

AVhen  gutta-percha  is  used  in  this  way,  or  "vvhen  it  is  employed 
for  sealing  medicaments  in  proximal  cavities  or  for  any  tem- 
porary purpose,  it  should  be  so  built  out  buccally  and  lingually 
as  to  impinge  on  the  buccal  and  lingual  festoons  of  gum  to  force 
them  back  on  a  level  with  the  gum  midway  between  the  teeth. 
There  are  two  reasons  for  doing  this.  It  keeps  the  festoons  out 
of  the  way  during  the  operation,  thus  preventing  their  laceration 
by  files  or  finishing  strips  and  affording  better  access  to  the  work, 
and  it  also  leaves  the  gum  in  the  best  possible  condition  for  re- 
occupying  the  interproximal  space  after  the  operation.  If  the 
festoons  are  left  higher  than  the  gum  between  the  teeth,  it  results 
in  an  inverted  arch  or  pocket  into  which  food  may  pack,  thus  re- 
tarding the  healthy  growth  of  the  gum.  If  the  festoons  are 
pressed  back  so  that  they  are  not  lacerated  and  a  favorable  form  is 
left  to  the  gum  after  operating,  it  will  be  found  that  the  gum  will 
quickly  creep  back  into  the  space  and  occupy  it  in  a  healthy  condi- 
tion. 

Details  of  Cavity  Formation. 

In  those  cases  where  the  occlusal  wall  is  still  standing  and  it 
becomes  necessary  for  the  operator  to  break  it  down,  it  is  a  matter 
of  some  importance  to  know  how  to  do  it  to  the  best  advantage. 
The  arch  of  enamel  overhanging  the  cavity  at  this  point  is  often 
strongly  resistant,  and  if  the  attempt  is  made  to  crush  it  in  with  a 
chisel,  as  is  frequently  done  by  operators,  the  result  is  ordinarily 
a  somewhat  severe  shock  to  the  patient.  This  shock,  coming  in 
the  early  stages  of  the  operation,  has  a  tendency  to  unnerve  the 
patient  and  create  an  apprehension  which  often  lasts  through  the 
entire  sitting.  As  has  already  been  intimated,  all  unnecessary  vio- 
lence must  be  avoided,  particularly  when  the  patient  first  takes  the 
chair. 

To  open  these  cavities  comfortably,  a  slot  should  be  drilled 
through  the  arch  as  illustrated  in  Fig.  60,  which  practically  re- 
moves the  keystone  of  the  arch  and  destroys  its  main  support. 
If  a  small  sharp  drill  be  used,  with  the  engine  revolving  rapidly, 
this  slot  may  be  made  without  appreciable  discomfort,  and  the  en- 
amel may  then  be  broken  down  with  a  chisel,  as  shown  in  Fig,  61, 


118 


PKINCIPLES    AND    PEACTICE    OF    FILLING    TEETH. 


The  chisel  should  be  held  at  the  angle  indicated  and  pressed 
firmly  against  the  enamel  to  prevent  gliding.  If  the  proper  angle 
be  maintained,  it  will  require  only  the  slightest  tap  of  the  mallet  to 
break  the  enamel  away.  Chisels  for  cleaving  enamel  should  be 
made  keenly  sharp,  so  that  they  "bite"  into  the  surface  imme- 
diately at  the  point  where  they  are  held,  instead  of  sliding  along 
the  surface  with  a  grating,  rasping  sensation  so  distressing  to 
most  patients. 

After  the  cavity  has  been  thoroughly  opened,  the  walls  may  be 
formed  as  follows: 

The  gingival  wall.- — The  margin  of  this  wall  should  be  extended 
far  enough  rootwise  to  carry  it  well  under  the  gum  in  accord- 
ance with  the  outline  in  Fig.  51.     The  degree  of  extension  will 


Fig.  60. 


Fig.  61. 


Fig.  62. 


Fig.  63. 


Fig.  64.       Fig.  65. 


differ  in  different  cases.  In  those  teeth  where  there  has  been  little 
decay  and  where  the  gum  fills  the  interproximal  spaces  normally 
to  the  contact  points,  it  will  not  require  much  extension  to  bring 
the  margin  safely  under  the  gum,  but  in  mouths  where  the  gums 
have  receded  in  the  spaces  and  where  the  tendency  to  proximal 
decay  is  great,  it  will  call  for  more  extensive  cutting  to  insure  a 
permanent  operation. 

The  form  of  the  wall  bucco-lingually  should  be  fiat,  and  it 
should  be  made  wide  enough  in  this  direction  to  furnish  a  broad 
base  for  the  filling  to  rest  upon  and  to  bring  the  gingivo-buccal  and 
gingivo-lingual  angles  to  a  point  of  safety  against  recurrence  of 
decay.  The  wall  should  also  be  flat  mesio-distally,  and  it  should 
join  the  axial  wall  at  right  angles.  In  some  instances,  where  great 
security  of  the  filling  is  required,  or  where  it  may  seem  difficult  to 
start  the  filling,  the  wall  may  be  made  to  dip  slightly  rootwise  as  it 
approaches  the  axial  wall,  but  a  groove  should  not  be  drilled  along 


CLASSIFICATION    AND    PREPAKATION    OF    CAVITIES.  110 

the  gingival  wall,  as  is  often  advocated.  To  groove  this  wall  re- 
sults in  the  formation  of  a  ridge  of  tissue  along  the  margin  of  the 
cavity,  against  which  it  is  difficult  to  adapt  gold  without  injuring 
the  enamel. 

As  the  gingival  wall  joins  the  buccal  or  lingual  wall  it  should 
form  a  distinct  angle  in  the  axial  region,  but  should  execute  a 
short  curve  at  the  enamel-margin.  The  angle  thus  formed  in  the 
gingivo-linguo-axial  corner  of  the  cavity  forms  an  excellent  means 
for  securing  the  first  pieces  of  gold  in  position,  and  the  general 
form  of  the  gingival  wall  when  shaped  as  just  outlined  affords  a 
base  upon  which  the  filling  may  be  built  without  danger  of  the 
gold  rocking  under  the  plugger-point.  A  rounded  gingival  wall, 
or  in  other  words  a  curved  base,  is  responsible  for  much  of  the 
difficulty  experienced  by  some  operators  in  starting  these  fillings. 

The  width  of  the  wall  mesio-distally  must  be  governed  by  the 
extent  of  tooth-tissue  available.  The  cavity  should  have  as  wide 
a  base  as  possible  without  endangering  the  pulp.  In  this  con- 
nection the  location  of  the  pulp-chamber  in  the  various  teeth 
should  be  carefully  studied  by  the  operator,  so  that  he  may  judge 
intelligently  how  far  he  can  extend  his  cavities  with  safety.  Fig. 
G2  illustrates  a  section  of  a  bicuspid  mesio-distally  with  the  form 
of  the  gingival  wall. 

The  buccal  and  lingual  walls. — As  already  intimated,  the  form 
usually  given  these  walls  by  operators  is  to  groove  them  Avith  the 
idea  of  anchoring  the  filling, — the  limitations  of  which  method 
have  already  been  pointed  out.  There  are  some  cases,  it  is  true, 
where  these  walls  must  be  made  to  sustain  the  filling;  such,  for 
instance,  as  lower  first  bicuspids  with  an  exceedingly  long  buccal 
cusp  and  a  diminutive  lingual  cusp  joined  by  a  perfect  fusion  of 
enamel.  In  these  cases  we  have  no  opportunity  for  creating  a  step 
on  the  occlusal  surface,  and  really  little  necessity  for  doing  so, 
owing  to  the  conical  shape  of  the  teeth  and  the  consequent  limited 
tipping  stress  on  the  filling.  The  occlusal  surface  of  a  proximal 
filling  in  one  of  these  teeth  presents  a  sloping  surface  to  the 
cusp  of  the  upper  tooth,  and  there  is  practically  no  leverage  to  dis- 
lodge it.      A   -light  buccal  and  lingual  retention  in  the  form  of 


120  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

shallow  grooves  in  connection  with  a  broad,  flat  seat  or  gingival 
wall  is  all  that  is  required  to  retain  the  filling. 

But  for  ordinary  cases  grooving  along  these  walls  should  be 
avoided;  though  a  possible  retentive  shape  should  not  be  ignored 
in  their  formation.  This  may  be  secured  by  making  an  angle 
between  these  walls  and  the  axial  wall  in  such  a  way  that  the  cavity 
is  slightly  wider  bucco-lingually  at  the  axial  wall  than  it  is  at  the 
dentinal  enamel-margin.  (Fig.  63.)  This  may  be  done  without 
materially  weakening  the  walls,  and  the  mortise  or  dovetail  form 
thus  provided  is  an  element  of  security  to  the  filling.  This  mor- 
tised effect  should  be  carried  'from  the  gingival  wall  throughout 
the  length  of  the  buccal  and  lingual  walls  till  they  approach  the 
enamel  on  the  occlusal  surface,  where  they  should  merge  into  the 
form  shown  in  Fig.  52,  c.  This  kind  of  wall  presents  a  surface 
against  which  gold  may  readily  be  adapted,  and  the  filling-material 
once  locked  between  these  two  perpendicular  walls  is  securely  held 
in  place.  The  building  of  fillings  in  cavities  thus  formed  is  a  very 
simple  matter. 

The  step. — This  should  be  cut  at  right  angles  with  the  prox- 
imal portion  of  the  cavity,  and  should  present  a  flat  base  for  the 
filling-material  to  rest  upon.  Its  width  bucco-lingually  and  its 
depth  pulpally  should  be  governed  by  the  form  of  the  tooth.  If  it 
is  a  short,  thick  tooth,  the  step  should  be  made  correspondingly 
wide,  with  a  diminished  depth,  while  if  the  tooth  be  long  and  thin 
the  step  may  be  narrowed  and  deepened^  The  object  in  any  case 
is  to  secure  a  sufficient  bulk  of  filling-material  in  the  step  to  afford 
strength, — which  is  particularly  true  at  the  point  where  the  step 
joins  the  proximal  portion  of  the  cavity.  The  step  should  be 
made  as  wide  and  deep  here  as  is  practicable  without  undermining 
the  cusps  or  weakening  the  tooth  between  the  cusps  so  as  to  render 
it  liable  to  split.  Particular  study,  especially  in  bicuspids,  should 
be  given  to  this  question  of  splitting  in  its  relation  to  the  depth  of 
the  step  pulpally.  A  safe  rule  to  follow  is  to  drill  as  deeply  be- 
tween the  cusps  as  the  fissure  extends  pulpally,  and  make  the  base 
of  the  step  at  this  point.  This  cannot  result  in  any  greater  ten- 
dency to  fracture  than  existed  before,  because  of  the  fact  that 


CLASSIFICATION    AND    PREPAKATIOX    OF    CAVITIES.  121 

wherever  there  is  a  fissure  there  is  no  binding  strength  repre- 
sented thronghout  its  extent. 

The  buccal  and  lingual  walls  of  the  step  should  be  made  per- 
pendicular, with  an  angle  between  them  and  the  pulpal  wall.  The 
end  of  the  step  most  remote  from  the  proximal  portion  of  the 
cavity  should  also  have  a  perpendicular  form,  and  the  step  at  this 
point  may  often  be  widened  bucco-lingually  in  those  teeth  having 
a  notable  depression  on  the  occlusal  surface  at  the  termination  of 
the  fissure.  This  results  in  a  dovetail  form  which  aids  in  the  reten- 
tion of  the  filling. 

The  axial  wall. — The  shape  of  this  wall  will  be  governed  mate- 
rially by  the  depth  of  the  decay.  Where  there  is  little  penetration 
of  the  carious  process  it  should  be  made  perpendicular  and  at 
right  angles  with  the  gingival  wall.  In  cases  of  deep  decay  with 
a  concave  axial  wall  it  may  be  well  to  create  a  new  axial  Avail  with 
cement,  which  will  afford  protection  to  the  pulp  and  give  a  better 
form  to  the  filling.  The  cement  should  not  be  built  out  so  far 
as  to  result  in  leaving  the  metal  filling  too  thin  for  strength. 
Veneer  fillings  of  this  character  cannot  be  depended  on  for  ex- 
tended service.  The  axial  wall  should  never  be  left  sloping  from 
the  step  to  a  narrow  gingival  wall,  on  account  of  the  tendency  of 
the  filling  to  shift  under  stress  when  built  against  an  inclined 
surface  such  as  this  would  present. 

The  enamel-margins. — The  buccal  and  lingual  margins  should 
be  beveled  to  a  greater  extent  than  in  any  other  part  of  the  outline 
of  the  cavity.  The  gingival  margin  need  be  beveled  but  very  little 
on  account  of  the  lack  of  lateral  violence  against  such  a  surface, 
and  also  because  of  the  difficulty  of  producing  a  perfect  bevel  in 
this  region  and  building  the  gold  over  it.  On  the  occlusal  surface 
the  slope  of  the  enamel  down  to  the  cavity-margin  and  the  proper 
shaping  of  the  walls  result  in  a  margin  which  requires  very  little 
beveling  by  the  operator.  Care  must  of  course  l)e  exercised  that 
in  forming  the  margins  no  overhanging  enamel  be  left.  If  the 
slightest  ledge  of  unsupported  enamel  is  allowed  to  remain,  it  will 
quickly  be  fractured  by  the  stress  of  mastication. 

Technique. — In  opening  the  cavity  all  friable  or  overhanging 


12'2  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

enamel  should  be  broken  down  by  chisels,  and  in  this  connection 
some  study  should  be  made  of  the  proper  angle  at  which  a  chisel 
must  be  held  in  order  to  cleave  enamel  to  the  best  advantage. 
Enamel  Avill  bear  appreciable  pressure  without  fracture  if  the  force 
is  exerted  upon  it  in  certain  directions,  but  a  slight  deviation  of 
the  force  may  be  made  to  result  in  a  ready  parting  of  the  enamel- 
prisms.  Advantage  should  be  taken  of  this  characteristic  of 
enamel  so  that  overhanging  walls  may  be  broken  down  with  the 
least  possible  force.  Little  can  be  definitely  taught  as  to  the 
precise  angle  at  which  the  chisel  should  be  held  for  the  best  results 
in  varying  cases,  but  the  observant  operator  will  readily  learn  to 
detect  the  vulnerable  points  in  overhanging  enamel  and  know  best 
how  to  attack  it. 

The  character  of  the  force  exerted  on  the  chisel  also  becomes  im- 
portant. Wherever  an  angle  of  enamel  is  to  be  broken  down  or 
where  there  is  any  appreciable  bulk  of  tissue  to  be  cleaved  away, 
it  is  best  and  most  comfortably  accomplished  by  a  sharp,  decisive 
blow  of  the  mallet  on  the  chisel.  But  where  it  is  merely  a  question 
of  cavity  extension  or  a  trimming  of  ragged  or  frail  walls,  hand 
pressure  on  the  chisel  is  preferable.  When  used  in  this  way  care 
should  be  exercised  not  to  allow  the  chisel  to  slip  into  the  cavity 
and  impinge  on  sensitive  tissue.  The  hand  should  be  guarded  and 
kept  under  perfect  control  by  bracing  the  ends  of  the  fingers — the 
ones  not  used  in  holding  the  chisel — firmly  against  the  teeth. 
This  work  may  in  certain  positions  be  best  accomplished  by  grasp- 
ing the  chisel  in  the  palm  of  the  hand  and  allowing  the  end  of  the 
thumb  to  rest  against  the  teeth  as  a  brace. 

The  next  step  is  to  give  form  to  the  cavity-walls.,  An  inverted 
cone  bur  of  sufificient  size  to  cover  the  gingival  wall  mesio-distally 
should  be  placed  with  its  end  on  this  wall,  as  illustrated  in  Fig.  64, 
and  carried  buccally  and  lingually  along  the  wall  till  the  proper 
extension  is  reached.  This  will  give  a  flat  form  to  the  gingival 
wall  and  create  an  angle  between  it  and  the  axial  wall.  Care 
should  be  exercised  that  the  blades  of  the  bur  do  not  penetrate  too 
close  to  the  pulp.  The  buccal  and  lingual  walls  may  often  be 
extended  with  the  same  bur  by  carrying  it  up  and  down  along  these 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES.  123 

walls, — cutting  with  the  side  of  the  bur.  In  lower  teeth,  or  in 
distal  cavities  difficult  of  access  in  upper  teeth,  an  inverted  cone  bur 
in  the  right-angle  hand-piece  will  be  most  effective.  After  the 
walls  have  been  extended  with  the  large  bur  it  will  be  found  that 
the  angles  betM'een  the  buccal  and  axial  or  lingual  and  axial  walls, 
and  particularly  in  the  gingivo-bucco-axial  and  gingivo-linguo- 
axial  corners,  are  not  sufficiently  well  defined.  A  smaller  in- 
verted cone  bur  used  in  the  same  way  may  be  carried  into  these 
angles  to  deepen  them,  and  if  a  still  shai-per  angle  be  required  it 
can  be  made  with  hatchet  or  hoe  excavators. 

As  the  small  inverted  cone  bur  is  being  used  along  the  gingival 
wall  it  should  be  carried  laterall}^  somewhat  into  the  buccal  and 
lingual  walls  at  this  point  and  then  withdrawn  a  short  distance 
crownwise  along  the  gingival  third  of  these  walls.  This  will  result 
in  an  angle  or  pocket  into  which  the  first  pieces  of  gold  may  readily 
be  secured.  Such  a  form  as  this  is  especially  serviceable  for  begin- 
ners, who  may  otherwise  find  difficulty  in  starting  these  fillings. 
If  there  be  much  softened  dentine  along  the  axial  wall  it  may  be 
removed  with  spoon  excavatoi*s. 

In  forming  the  step,  the  fissure  on  the  occlusal  surface  may  be 
opened  up  with  a  small  drill,  a  suitable  form  for  this  purpose  being 
readily  made  from  a  worn-out  inverted  cone  bur  by  grinding  it  on 
two  sides  to  a  sharp  edge,  as  illustrated  in  Fig.  65.  This  form  of 
drill,  small  in  size  and  ground  sharp,  may  be  made  to  walk  directly 
through  between  the  two  plates  of  enamel  bordering  a  fissure  by 
revolving  the  engine  rapidly  and  swaying  the  hand-piece  back  and 
forth,  so  that  the  sharp  corners  of  the  drill  effectively  bite  into  the 
enamel.  AVlien  a  narrow  trench  is  thus  made  it  may  be  widened 
with  a  chisel,  after  which  the  floor  of  the  step  may  be  formed  with 
an  inverted  cone  bur  stood  with  its  end  on  the  step.  This  results 
in  the  desired  flat  base  to  the  step,  while  the  sides  of  the  bur  give 
form  to  the  walls. 

The  gingival  enamel-margin  may  be  given  the  slight  degree  of 
l>evel  necessary  with  suitably  formed  chisels  or  long-shanked  ex- 
cavators. Sometimes  in  cases  of  good  access  a  round  bur  may  be 
passed  along  this  margin  to  advantage.     For  beveling  the  buccal 


124  PKIiSrCIPLES    AND    PKACTICE    OF    FILLING    TEETH. 

and  lingual  enamel  a  thin,  sharp  chisel  may  be  used  to  plane  down 
the  peripheral  margin,  but  what  is  far  preferable  in  those  cases 
where  it  can  be  used  is  a  sand-paper  disk  in  the  engine.  This,  if 
held  at  a  definite  angle,  will  give  the  required  bevel,  and  will  leave 
a  margin  clearly  cut,  symmetrical,  and  smooth.  Care  must  of 
course  be  exercised  not  to  round  the  margin  with  the  disk  by  sway- 
ing the  hand-piece  as  the  disk  is  revolving. 

General  Considerations. 

While  the  form  of  cavity  here  recommended  is  believed  to  be  the 
best  adapted  for  the  majority  of  cases  applying  to  the  dentist,  it  is 
acknowledged  that  there  are  many  instances  where  it  cannot  well 
be  followed  out  in  all  of  its  details.  The  extent  of  the  decay  is 
sometimes  so  great  as  to  determine  the  shape  of  the  cavity-walls, 
and  where  there  has  been  much  undermining  of  the  tissue  the 
operator  is  left  to  make  the  most  of  the  opportunities  presented; 
but  the  principles  involved  in  cavity  formation  should  never  be 
lost  to  view,  and  every  cavity  should  be  made  to  conform  to  them 
as  accurately  as  the  case  will  permit. 

A  distinction  is  sometimes  made  in  these  cavities  between  those 
intended  for  gold  and  those  for  amalgam.  So  far  as  the  general 
form  of  the  cavity  is  concerned,  there  should  be  no  distinction, 
except  that  for  amalgam  more  extensive  anchorage  is  usually 
required  than  for  gold.  Gold  if  properly  condensed  is  so  stable 
and  uniform  in  its  behavior  that  it  may  be  depended  on  to  remain 
placed  in  a  cavity  where  amalgam  with  its  freaks  and  fancies  will 
too  often  prove  insecure.  With  most  of  the  amalgams  in  use  it 
requires  a  much  greater  bulk  of  the  material  to  stand  a  given  stress 
than  it  does  of  gold,  and  the  anchorages  must  therefore  be  broader 
and  deeper,  and  the  bevel  of  enamel  along  the  margins  not  quite 
so  great.  With  these  exceptions  the  plan  of  cavity  formation 
should  be  the  same. 

One  feature  relative  to  the  security  of  these  fillings  in  bicuspids 
and  molars  should  not  be  overlooked  in  estimating  the  extent  of 
anchorage  required.  It  is  too  often  the  case  that  operators  insert 
these  fillings  without  an  adequate  study  of  the  kind  of  service  they 


CLASSIFICATION    AND    PKEPARATION    OF    CAVITIES.  125 

are  destined  to  perform.  Even  if  they  stop  to  consider  the  force 
of  mastication  in  its  relation  to  the  extent  of  anchorage,  it  is  usually 
only  with  the  idea  of  a  given  number  of  pounds  pressure  which 
may  be  exerted  on  the  filling,  and  the  probability  of  a  certain  area 
of  anchorage  withstanding  such  a  pressure.  They  do  not  con- 
sider in  its  full  significance  the  feature  of  aggregate  service.  It  is 
the  constant  dripping  of  water  which  wears  away  the  stone,  and  in 
anchoring  these  fillings  we  must  provide  against  a  series  of  masti- 
cating impacts  so  numerous  in  extent  as  to  stagger  one  who  has- 
not  studied  the  matter.  Persons  vary  greatly  in  the  number  of 
occlusions  they  make  during  a  meal,  as  they  do  in  the  degree  of 
force  used  in  masticating,  but  a  somewhat  close  observation  would 
lead  to  the  belief  that  for  the  proper  mastication  of  an  average 
dinner  the  individual  will  make  at  least  one  thousand  distinct 
occlusions,  and  in  many  instances  it  will  greatly  exceed  this.  Let 
us  stop  to  consider  what  this  means  for  our  filling.  Suppose  one- 
half  of  these  impacts  fall  on  one  side  and  that  one-half  of  these 
come  against  the  filling.  This  is  really  a  low  estimate,  because 
many  persons  will  manage  a  bolus  of  food  on  each  side  of  the 
mouth  at  the  same  time,  and  this  bolus  will  extend  over  several 
teeth.  At  a  moderate  computation  each  meal  will  result  in  nearly 
three  hundred  impacts  of  food  against  the  filling,  varying  in  force 
and  character  according  to  the  habit  of  the  individual  and  the 
nature  of  the  food.  When  it  is  remembered  that  this  process  is 
kept  up  three  times  a  day  for  three  hundred  and  sixty-five  days 
in  the  year,  it  will  soon  become  manifest  that  our  fillings  must  be 
anchored  against  some  pretty  severe  usage,  and,  with  such  a  reck- 
oning as  this  constantly  before  him,  the  conscientious  operator  will 
proceed  to  his  work  with  the  greatest  care  and  thoroughness  to 
the  end  that  it  may  be  made  as  permanent  as  possible. 

A  close  study  of  the  process  of  mastication  in  the  operator's 
own  mouth  in  its  relation  to  this  subject  is  strongly  recommended. 
The  nature  and  extent  of  the  force  used,  together  with  the  manner 
of  its  application  in  the  comminution  of  different  food  materials, 
are  fit  subjects  for  careful  observation;  and  an  intelligent  compre- 
hension of  the  forces  at  work  in  the  performance  of  mastication 


126  PEIJfCIPLES    AKD    PRACTICE    OF    FILLING    TEETH. 

will  place  the  operator  in  a  better  position  to  render  the  most  per- 
fect service. 

Buccal,  Labial,  or  Lingual  Cavities. 

All  cavities  occurring  in  either  of  the  three  surfaces — buccal, 
labial,  or  lingual — call  for  similar  treatment  so  far  as  the  prin- 
ciples of  cavity  formation  are  concerned,  except  the  small  rounded 
cavities  having  their  origin  in  the  pits  on  the  buccal  surfaces  of 
lower  molars  and  the  lingual  surfaces  of  the  upper  anterior  teeth. 
These  pitted  cavities  are  quite  distinct  in  character  and  environ- 
ment from  the  ordinary  buccal  and  lingual  decay  occurring  near 
the  gum-margin,  and  their  preparation  is  so  self-evident  as  not  to 
call  for  any  extended  or  detailed  description.  The  fact  that  they 
are  usually  the  result  of  structural  imperfections  in  the  tooth  at 
the  point  of  decay,  and  that  they  occur  in  surfaces  which  are  ordi- 
narily readily  cleansed  by  friction,  renders  it  necessary  only  to 
remove  the  carious  and  imperfect  tissue,  secure  good  margins,  and 
give  a  mortised  form  to  the  cavity,  l^o  extension  for  prevention 
is-  required  in  these  cases. 

But  where  decay  occurs  near  the  gum-margin  and  extends  in  a 
crescent  form,  following  the  outline  of  the  gum  along  the  surface 
of  the  tooth,  the  problem  of  its  control  becomes  more  complicated. 
These  are  sometimes  accounted  the  most  difficult  of  all  cavities  to 
deal  with,  and  yet  if  properly  managed  they  will  respond  to  treat- 
ment with  most  gratifying  results. 

The  cavity  outline. — The  proper  marginal  outline  of  the  cavity 
becomes  a  matter  of  vital  importance  in  its  relation  to  the  probable 
permanence  of  the  operation.  The  reason  that  many  of  these  fill- 
ings fail  so  early  after  their  insertion  may  be  traced  to  the  fact  that 
in  the  preparation  of  the  cavity  the  margins  are  not  extended  to 
include  all  of  the  affected  enamel.  If  we  study  the  manner  of 
progress  of  this  form  of  decay,  it  will  enlighten  us  greatly  as  to  the 
necessities  of  the  case  in  treatment.  Occasionally  we  may  find 
these  cavities  well  defined  in  outline  with  a  notable  penetration  of 
decay  at  a  given  point,  and  when  such  is  the  case  with  a  surround- 
ing surface  of  perfect  enam.el  our  method  of  procedure  is  clear* 
We  need  very  little  extension  of  the  margins. 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES.  127 

But  in  the  vast  majority  of  cavities  occurring  in  these  surfaces 
it  will  be  found  that  the  area  of  decay  is  ill  defined,  and  that  the 
enamel  is  more  or  less  disintegrated  along  the  surface  leading  from 
the  cavity  and  following  the  margin  of  the  gum.  This  affected 
enamel  must  invariably  be  included  in  the  cavity  outline  and 
replaced  by  filling-material  if  we  are  to  be  assured  of  permanent 
results.  The  fact  that  disintegration  has  commenced  is  conclusive 
evidence  that  the  active  agent  of  caries  has  found  this  particular 
point  of  the  surface  a  suitable  field  upon  which  to  work  its  destruc- 
tive processes,  and  the  assumption  is  clear  that  unless  the  condi- 
tions are  radically  changed  the  process  will  continue.  The  surest 
method  of  changing  the  conditions  is  to  remove  the  area  of  tissue 
upon  which  the  micro-organisms  of  caries  are  known  to  act,  and 
replace  it  with  filling-material  upon  which  they  cannot  act.  This 
one  fact  that  enamel  is  vulnerable  to  the  attack  of  micro-organisms, 
while  filling-material  is  not,  should  give  us  a  clearer  conception  of 
the  required  line  of  treatment  in  all  those  positions  which  are  sub- 
ject to  the  influence  of  the  destructive  agent.  The  broader  we 
make  our  metal  surface  at  the  expense  of  the  enamel-surface,  the 
more  certain  we  are  to  avoid  a  recurrence  of  decay,  and  yet  this 
does  not  imply  that  Ave  must  ruthlessly  or  ill-advisedly  carve  away 
sound  enamel  for  the  purpose  of  making  a  broad  metallic  area. 
It  simply  implies  that  we  shall  not  stop  short  of  reaching  perfectly 
sound  enamel  in  the  extension  of  these  cavities,  and  that  particu- 
larly in  positions  suitable  for  the  lodgment  of  micro-organisms  we 
shall  be  especially  thorough. 

The  surface  of  the  enamel  surrounding  one  of  these  cavities 
must  be  critically  examined  for  defects.  Sometimes  a  crescentic 
line  of  discoloration  extends  from  the  cavity  in  such  a  manner  as 
to  confuse  the  operator  with  regard  to  the  true  condition  of  the 
enamel  under  it.  It  may  be  simply  a  discoloration  on  the  surface, 
with  sound  enamel  below  it,  or  the  enamel  may  be  softened  to  con- 
siderable depth  and  the  discoloration  tend  to  hide  the  defect.  The 
only  way  to  determine  the  true  condition  of  the  enamel  is  to  thor- 
oughly polish  away  the  discoloration  with  pumice  carried  on  a 
brush  in  the  engine.     If  the  ])rush  succeeds  in  removing  all  the 


128  PEIiS^CIPLES    AI\'D    PRACTICE    OF    FILLING    TEETH. 

discoloration,  leaving  a  white  and  glistening  surface  to  the  enamel, 
we  may  know  that  the  destructive  agent  of  caries  has  not  yet 
affected  it;  but  if  the  enamel  shows  disintegration  on  its  surface 
after  the  brush  has  been  used,  we  must  cut  out  this  disintegrated 
tissue,  even  if  it  has  not  already  penetrated  the  entire  depth  of  the 
enamel. 

The  proper  extension  of  the  cavity  rootwise  involves  the  carrv'- 
ing  of  this  margin  well  under  the  gum.  There  are  two  reasons  for 
this, — first,  the  one  already  given  in  connection  with  proximal 
cavities,  that  wherever  the  filling  is  carried  under  the  free  margin 
of  the  gum  there  "will  be  no  recurrence  of  decay  at  that  point,  and 
second,  that  the  gum  is  more  likely  to  remain  healthy  when  over- 
lapping a  smooth  gold  filling  than  when  overlapping  tooth-tissue, 
particularly  if  there  has  been  any  recession  of  the  gum.  This 
latter  statement  may  appear  illogical  at  first  thought,  but  a  some- 
what close  clinical  observation  would  seem  to  confirm  it  beyond 
any  doubt,  and  a  careful  study  of  the  conditions  will  suggest  a 
tenable  reason  therefor.  In  all  cases  where  there  has  been  any 
extended  decay  it  will  be  found  that  the  margin  of  the  gum  has 
been  interfered  mth  in  one  of  two  ways.  Either  the  decay  has 
crept  up  under  the  gum,  leaving  the  free  margin  lying  in  the 
cavity  in  an  unhealthy  condition,  or  else  the  gum  has  progressively 
receded  and  is  lying  against  the  cementum  instead  of  enamel.  In 
the  latter  case  the  gingival  outline  of  the  cavity  is  usually  ill 
defined,  with  little  penetration  of  the  carious  process.  Under 
either  of  these  conditions  the  gum  will  be  found  abnormal.  If  in 
the  preparation  of  the  cavity  we  press  back  the  gum  gently  but  to 
considerable  extent  and  make  the  gingival  margin  of  the  filling 
sufficiently  rootwise,  we  shall  find  that  the  gum  mil  rapidly  cover 
it  in  a  healthy  condition.  jSTot  only  this,  but  in  many  cases  the 
gum  mil  creep  so  far  crownwise  as  to  cover  the  neck  of  the  tooth 
and  filling  far  in  excess  of  its  position  before  the  operation.  It  ap- 
parently takes  more  kindly  to  a  smooth  gold  surface  than  it  does  to 
cementum  which  may  be  denuded,  or  to  enamel  which  may  be 
slightly  roughened.  Some  extreme  cases  of  this  kind  of  gum- 
reproduction  have  been  noted,  particularly  in  cuspids,  where  the 


CLASSIFICATIO^^    AND    PKEPAKATION    OF    CAVITIES.  129 

gum  has  been  knoAvn  to  cover  the  gingival  portion  of  a  filling  to 
the  extent  of  over  two  millimeters.  Such  results  as  these  are  suffi- 
ciently gratifving  to  reward  the  operator  for  the  necessary  expends 
ture  of  energy,  and  the  patient  for  the  discomfort  accompanying 
the  work. 

In  Fig.  G6  will  be  seen  a  central  incisor,  with  the  cavity  a  pene- 
trating through  the  enamel,  h  defective  enamel  extending  from 
cavity,  and  c  the  proper  outline  of  filling. 

The  cavUy-ivalls. — The  plan  of  anchorage  for  these  fillings  is 
exceedingly  simple.  There  is  no  need  for  the  deep  undercutting 
sometimes  resorted  to  by  operators,  all  that  is  necessary  being  to 
give  a  mortised  form  to  the  cavity  by  making  the  axial  wall  flat 

Fig.  G7.  Fig.  68.  Fig.  G'J. 


and  the  surrounding  walls  at  right  angles  to  it.  At  two  points  in 
the  cavity  it  is  well  to  make  a  slight  dovetail  to  more,  securely  lock 
the  filling  into  place,  viz,  at  the  mesial  and  distal  extremities.  To 
this  end  the  axial  wall  should  be  made  slightly  wdder  mesio-distally 
than  the  orifice  of  the  cavity  at  the  dentinal  enamel-margin.  This 
is  especially  true  where  amalgam  is  to  be  used  on  the  buccal  or 
lingual  surfaces  of  molars.  Amalgam  requires  broader  and  deeper 
anchorages  to  hold  it  in  place  than  does  gold,  and  this  fact  should 
be  noted  particularly  in  those  cases  on  molars  where  the  cavity 
passes  so  far  mesially  and  distally  as  to  curve  somewhat  toward 
the  proximal  surfaces.  These  are  the  cases  where  amalgam  is  so 
often  seen  to  curl  away  from  the  cavity  at  the  extremities,  admit- 
ting a  leak  around  the  filling.  If  amalgam  is  to  be  held  securely 
in  position  in  buccal  or  lingual  cavities,  it  must  be  placed  in  broad, 
dovetailed  anchorages. 

Technique. — In  many  of  these  cavities  it  will  be  found  that 
while  the  enamel  is  completely  disintegrated  and  dissolved  away. 

9 


130  PKINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

the  dentine  maintains  practically  its  original  form,  being  simply 
softened  or  decalcified  for  considerable  depth  without  breaking 
down.  This  softened  mass  of  dentine  is  best  removed  with  a 
hatchet  excavator,  the  blade  of  which  is  thin,  delicate,  and  ex- 
ceedingly sharp.  The  keen  edge  of  the  blade  is  placed  on  end  at 
one  extremity  of  the  cavity  and  forced  to  the  full  depth  of  the 
decay.  Then  by  a  dextrous  turn  the  whole  carious  mass  is  rolled 
out  of  the  cavity  in  one  piece,  thus  removing  at  a  single  sweep  what 
is  ordinarily  the  most  sensitive  portion  of  the  tissue.  This,  if  done 
skillfully,  is  usually  not  a  very  painful  proceeding,  but  there  must 
be  no  half  measures  about  it.  Any  picking  or  manipulation  of 
the  carious  mass  bit  by  bit  is  simply  excruciating  as  well  as  ineffec- 
tive. The  operator  should  be  at  the  same  time  gentle  and  thor- 
ough. His  touch  should  be  delicate  and  forceful,  his  movements 
definite  and  rapid. 

When  the  softened  dentine  is  removed  with  the  excavator  the 
next  step  is  to  give  form  to  the  walls.  This  is  best  done  with  an 
inverted  cone  bur  stood  with  its  end  against  the  axial  wall,  Fig, 
67,  and  carried  mesially  and  distally  across  the  cavity  till  the  de- 
sired form  is  obtained.  This  kind  of  bur  gives  the  proper  shape 
to  the  walls  and  leaves  a  mortised  effect,  as  shown  in  Fig.  68.  As 
the  bur  approaches  the  mesial  and  distal  walls  of  the  cavity  it 
should  be  carried  somewhat  into  these  walls  to  give  a  dovetailed 
form,  as  illustrated  in  the  cross-section  of  an  incisor,  Fig.  69.  In 
posterior  teeth  inaccessible  to  the  straight  hand-piece  the  desired 
result  may  be  attained  by  using  an  inverted  cone  bur  in  the  right- 
angle  hand-piece. 

When  the  walls  are  formed  the  enamel-margins  may  be  beveled 
v/ith  a  sharp  chisel,  or,  what  is  preferable  when  properly  used,  a 
round  bur  in  the  engine.  This  must  be  kept  under  perfect  control 
and  made  to  follow  the  margin  without  slipping  out  of  place.  To 
maintain  a  bur  in  its  proper  position  in  following  the  margins  of  a 
cavity  it  is  often  advisable  to  let  the  shank  rest  on  a  support  or 
fulcrum  formed  by  some  adjacent  surface  of  the  enamel.  In  this 
way  the  bur  may  be  accurately  guided  along  the  margin  so  as  to 
cut  at  any  desired  angle.     A  more  perfect  symmetry  may  be  given 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES.  131 

to  a  margin  with  a  revolving  instrument  like  a  bur  than  is  possible 

with  a  chisel.     This  is  particularly  true  of  the  curves  in  the  cavity 

outline. 

General  Considerations. 

As  has  been  stated,  these  cavities  are  often  the  most  dreaded  of 
any  by  the  majority  of  operators.  That  they  present  elements  of 
difficulty  peculiar  to  themselves  is  undoubtedly  true,  but  if  treated 
on  correct  principles  they  are  in  many  respects  the  most  satis- 
factory of  all  filling-operations.  The  problem  of  anchorage  is 
exceedingly  simple  on  account  of  the  lack  of  any  stress  tending  to 
dislodge  the  filling.  The  marginal  outlines  of  the  cavity,  if  prop- 
erly formed,  are  comparatively  safe  from  recurrence  of  decay, 
through  the  fact  that  the  gum  completely  protects  the  gingival 
margin  and  the  other  margins  are  kept  clean  by  friction  of  the 
cheeks,  lips,  or  tongue.  The  open  aspect  of  these  cavities  admits 
of  an  accurate  placing  of  the  gold  and  a  close  scrutiny  of  the  mar- 
gins to  detect  and  correct  any  imperfections. 

The  chief  difficulties  of  management  relate  to  forcing  the  gum 
out  of  the  -way  sufficiently  to  admit  of  free  working,  to  keeping  the 
cavity  dry,  and  to  the  supposed  fact  that  these  cavities  are  usually 
more  sensitive  than  others.  As  to  the  latter  complication,  it  is 
counterbalanced  both  for  the  patient  and  operator  by  the  rapidity 
with  which  such  a  cavity  can  be  prepared,  and  the  discomfort  in 
the  aggregate  is  therefore  not  much  greater  than  with  other  cavi- 
ties of  similar  extent.  The  problem  of  managing  the  gum  and 
keeping  the  cavity  dry  is  simply  a  question  of  skill  and  "knack" 
which  may  be  acquired  by  almost  any  operator  who  will  give  a 
close  study  to  the  special  requirements  of  the  case.  With  this 
skill  once  developed  these  cavities  are  readily  brought  under  con- 
trol. 

Occlusal  Cavities  in  Bicuspids  and  Molars. 

These  cavities  are  usually  the  result  of  structural  imperfections 
in  the  tooth  by  which  the  developing  islands  of  calcification,  begin- 
ning at  the  tips  of  the  cusps,  have  failc<l  to  ])i\>perly  unite  on 
approaching  each  other,  loa\nug  a  leak  for  the  ingress  of  foreign 
njatter.      The  chief  considerations  in   the.  management  of  these 


132  PRINCIPLES    AND    PRACTICE    OF    PILLING    TEETH. 

cases  relate  to  the  breaking  down  of  overhanging  enamel,  the 
removal  of  decay,  the  obliteration  of  any  remaining  structural  im- 
perfections in  the  way  of  fissures  extending  from  the  cavity,  and 
the  proper  retentive  form  for  the  iilling. 

An  important  distinction  between  caries  occurring  upon  these 
surfaces  and  that  of  other  surfaces  already  considered  is  due  to  the 
fact  that  upon  occlusal  surfaces  decay  seldom  occurs  except  as  the 
result  of  defects  in  the  enamel,  while  on  the  others  it  is  often  found 
beginning  upon  perfectly  formed  enamel.  The  reason  for  this  is 
that  the  friction  of  mastication  very  largely  prevents  the  possibility 
of  decay  upon  the  occlusal  surfaces,  except  as  the  agent  of  caries 
is  harbored  in  some  crevice  or  fissure  where  the  cleansing  process 
of  mastication  cannot  reach.  On  this  account  extension  for  pre- 
vention is  seldom  indicated  in  occlusal  surfaces  unless  the  drilling 
out  of  all  fissures  running  from  the  cavity  may  be  so  interpreted. 

This  problem  of  the  treatment  of  fissures  is  one  indissolubly 
linked  with  the  management  of  these  occlusal  cavities.  Many 
operators  do  not  seem  to  consider  it  necessary  to  drill  out  fissures 
unless  actual  decay  has  begun  in  them.  They  overlook  two 
things, — the  difiiculty  of  making  a  good  margin  to  the  filling  at 
the  intersection  of  a  fissure,  and  the  real  nature  of  the  imperfection 
that  a  fissure  represents.  If  an  operator  has  any  doubt  as  to  the 
necessity  for  drilling  out  all  fissures  extending  from  a  cavity  under 
preparation,  let  him  make  a  microscopical  examination  of  sections 
of  teeth  cut  crosswise  of  a  fissure,  and  he  will  no  longer  hesitate. 
In  many  of  these  cases  where  the  orifice  of  the  fissure  is  so  narrow 
as  scarcely  to  admit  the  finest  exploring  instrument,  the  micro- 
scope will  show  a  decided  imperfection  reaching  entirely  through 
the  enamel,  as  indicated  in  Fig.  YO.  This  kind  of  a  break  in  the 
enamel-surface  is  a  serious  menace  to  the  tooth,  and  no  operator  is 
doing  his  duty  by  the  patient  when  he  leaves  such  a  defect  in  con- 
nection with  his  work.i  It  is  the  minutiae  which  count  in  dental 
practice,  and  microscopic  conditions  must  not  be  ignored. 

It  would  be  a  revelation  to  many  operators  to  turn  the  micro- 
scope upon  cases  similar  to  the  ones  they  are  treating  every  day, 
and  see  the  numberless  imperfections  which  the  unaided  eye  can- 


CLASSIFICATION    AND    PREPAEATION    OF    CAVITIES.  133 

not  detect.  One  of  these  fissures,  apparently  so  slight  as  to  be  of 
little  moment,  and  which  the  blunt  exploring  instruments  in  com- 
mon use  in  offices  will  scarcely  penetrate,  may  be  found  large 
enough  on  microscopical  examination  to  admit  a  whole  army  of 
micro-organisms  sufficient,  if  the  conditions  be  favorable,  to  under- 
mine the  tissue  in  a  few  months.  If  we  are  to  successfully  combat 
this  disease  of  dental  caries  we  must  be  observant  and  infinitely 
painstaking. 

Another  reason  for  drilling  out  these  fissures  and  filling  them  ia 
because  the  surface  of  the  tooth  is  thereby  rendered  more  perfect 
in  form.  In  almost  every  case  where  a  fissure  exists  there  will  be 
found  a  somewhat  notable  depression  in  the  enamel  leading  down 
to  it,  and  this  Y-shaped  sulcus  furnishes  a  receptacle  for  the  lodg- 

FiG.   70.  Fig.   71.  Fig.   72.       Fig.   73.    Fig.   74. 


ment  of  certain  kinds  of  food  material,  to  the  annoyance  and  dis- 
comfort of  the  patient.  Berry  seeds  and  other  like  substances  are 
especially  prone  to  lodge  in  these  depressions,  and  comfortable 
mastication  is  thus  interfered  with.  It  should  be  the  oflice  of  the 
dentist  to  correct,  if  possible,  any  faults  of  form  in  the  teeth  he  ia 
operating  on,  and  this  may  readily  be  done  in  the  case  of  fissures 
by  drilling  them  out  and  building  up  the  filling  as  illustrated  in 
Fig.  71.  This  change  in  the  form  of  the  occlusal  surface  does  not 
in  any  way  detract  from  the  efficiency  of  mastication,  because  the 
biting  force  of  the  cusps  of  the  opposing  tooth  will  be  fully  as 
effective — if  not  more  effective — when  exerted  against  a  moderate 
concavity  such  as  the  surface  of  the  filling  would  present,  as  it  will 
when  brought  to  bear  upon  a  V-shaped  depression. 

The  marginal  oullines. — The  outlines  of  the  different  cavities 
in  the  occlusal  surfaces  will  vary  greatly  according  to  the  kind  of 
tooth  and  the  particular  conditions  present  in  each  case.  The 
number  of  cusps  and  the  direction  of  the  fissures  seem  to  be  the 


13-i  PEIXCIPLES    AI^D    PRACTICE    OF    FILLING    TEETH. 

most  prominent  factors  in  determining  cavitv  outline,  wliile  the 
extent  of  decay  is  of  conrse  always  to  be  reckoned  with.  What 
may  be  considered  typical  cavity  outlines  are  here  illustrated  in  the 
different  teeth.  Fig.  T2  shows  the  occlusal  surface  of  an  upper 
bicuspid  with  tilling  in  place.  This  is  almost  universally  the  form 
for  these  teeth  where  the  slightest  decay  has  begun  upon  the  sur- 
face, even  if  only  one  pit  at  the  termination  of  the  central  groove 
has  been  affected.  The  reason  for  this  is  that  the  groove  is  nearly 
always  fissured  throughout  its  length,  and  even  when  not  fissured 
it  is  sufficiently  sulcate  to  prevent  the  proper  finish  of  a  filling 
against  its  intersection.  In  lower  bicuspids — ^particularly  in  the 
first — the  transverse  ridge  of  enamel  leading  from  the  buccal  cusp 
to  the  lingual  is  often  so  prominent  and  so  perfect  in  structure 
as  to  leave  no  central  o-roove,  thus  di^dding  definitely  the  mesial 


Fig.  75.  Fig.  76.  Fig.  77.  Fig.  78. 


and  distal  pits.  In  these  cases  the  pits  may  be  filled  separately,  as 
illustrated  in  Fig.  73.  In  the  lower  second  bicuspid  the  outline 
may  sometimes  simidate  that  of  the  upper  bicuspids,  while  in  occa- 
sional cases  we  find  three  cusps  on  this  surface,  necessitating  the 
outline  given  in  Fig.  74.  In  the  upper  molars  there  are  usually 
two  cavities  corresponding  to  the  central  and  distal  pits,  as  shown 
in  Fig.  75,  or  the  disto-lingual  groove  may  be  fissured  throughout 
its  length,  resulting  in  an  outline  such  as  that  in  Fig.  76.  In  cases 
of  extensive  decay,  where  the  oblique  ridge  of  enamel  between  the 
central  and  distal  pits  is  so  seriously  undermined  as  to  jeopardize 
its  stability,  it  should  be  cut  away  and  a  cavity  formed  like  the  one 
in  Fig.  77. 

It  is  sometimes  a  point  of  nice  distinction  to  determine  whether 
this  ridge  shall  be  left  standing  or  be  broken  do^vn,  the  decision 
being  based  principally  upon  two  factors, — the  extent  of  dentine 
supporting  it  and  the  depth  of  the  distal  groove.  If  it  is  not  well 
supported  by  dentine  it  will  prove  an  element  of  weakness  between 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES.  135 

the  two  lilliugs,  and  if  the  groove  is  sufficiently  deep  to  present  a 
notable  depression  at  this  point  it  will  leave  an  undesirable  form  to 
the  surface.  The  operator  must  decide  on  the  basis  of  long-con- 
tinued usage  in  the  future  rather  than  from  past  usage  or  a  tem- 
porary service.  One  condition  in  this  connection  is  calculated  to 
mislead  an  unobservant  operator,  and  this  holds  true  as  well  of 
other  walls  on  the  occlusal  surfaces  as  of  the  one  under  considera- 
tion. The  fact  that  a  certain  wall  has  stood  without  fracture  up 
to  the  time  of  the  operation  is  often  accepted  as  an  indication  that 
it  may  safely  be  left  around  a  filling.  The  argument  is  used  that 
if  it  has  not  broken  when  surrounding  a  cavity  it  certainly  will 
not  break  when  reinforced  by  a  filling,  but  an  important  factor  in 
the  case  is  overlooked.  When  a  tooth  begins  to  decay  it  is  often 
more  or  less  sensitive  under  mastication,  and  the  patient  involun- 
tarily forms  the  habit  of  favoring  the  tooth  so  that  it  does  not 
receive  its  full  share  of  masticating  usage.  The  decay  progresses 
till  the  enamel  is  so  undermined  as  to  leave  very  weak  walls,  which 
may  stand  indefinitely  under  these  conditions,  so  far  as  the  stress 
of  mastication  is  concerned.  But  when  the  cavity  is  filled  and  the 
tooth  rendered  comfortable,  the  patient  gradually  begins  to  use  it 
again,  and  the  consequence  is  often  fractured  walls  wdien  the 
operator  had  judged  them  to  be  safe.  The  highest  class  of  service 
to  our  patients  demands  the  closest  insight  into  all  of  the  factors 
making  for  or  against  the  success  of  our  operations. 

The  cavity  outlines  on  lower  molars  differ  from  those  on  upper 
molars,  and  there  is  also  a  variation  between  the  lower  first  molar 
and  lower  second  molar.  The  lower  first  molar  has  five  cusps 
intersected  by  grooves  which  are  frequently  fissured,  thus  resulting 
in  a  cavity  outline  such  as  is  illustrated  in  Fig.  78.  Occasionally 
the  buccal  groove  and  the  disto-buccal  groove  are  fissured 
throughout  their  length,  which  would  result  in  the  filling  being 
f-arried  over  on  the  buccal  surface  to  the  full  extent  of  the  fissure. 
AVhcn  this  is  done  the  buccal  extremity  of  the  cavity  should  pre- 
sent th(;  form  in  Pig.  79.  The  lower  second  molar,  having  fouj- 
cusps,  calls  for  a  (;avity  outline  similar  to  tliat  in  Fig.  80.  The 
tliird  molars,  ii|)|K'r  and  lower,  are  so  variable  in  form  as  to  pre- 


136  PEIiSrCIPLES    A^D    PRACTICE    OF    FILLING    TEETH. 

elude  the  possibility  of  suggesting  anything  like  a  uniform  cavity 
outline  in  either  of  them,  each  case  calling  for  special  consideration 
as  it  presents  itself. 

The  cavity-walls. — The  walls  surrounding  these  cavities  should 
be  perpendicular,  or  in  line  with  the  long  axis  of  the  tooth.  The 
pulpal  wall  or  seat  should  be  horizontal  or  flat,  and  should  join  the 
other  walls  at  right  angles.  (Fig.  81.)  This  is  particularly  true 
of  the  mesial,  distal,  buccal,  and  lingual  extremities  of  the  cavity. 
On  account  of  the  difficulty  of  making  a  perpendicular  wall  at  the 
termination  of  a  fissure,  the  cavity  extremities  are  sometimes  left 
as  illustrated  in  Fig.  82,  a.  This  is  an  incorrect  form,  no  matter 
how  well  the  filling  may  be  anchored  in  other  parts  of  the  cavity. 
In  every  case  it  should  be  formed  as  in  Fig.  82,  h.     The  reason  for 

Fig.  79.  Fia.  80.  Fig.  81.         Fig.  82. 


^1.  mW'l 


this  is  that  the  extremities  of  the  fillings  formed  like  that  at  a  are 
likely  to  be  lifted  out  of  place  in  the  mastication  of  adhesive  mate- 
rials such  as  candies,  etc. 

The  depth  of  the  cavity  pulpally  is  governed  in  the  carious  por- 
tion by  the  extent  of  decay,  and  in  the  fissured  portions  by  the 
depth  of  the  fissure.  It  will  be  found  that  anything  short  of  a 
full  extension  to  the  depth  of  the  fissure  will  result  in  so  shallow  a 
cavity  as  to  render  the  filling-material  weak.  jSTumerous  failures 
of  portions  of  these  fillings  along  fissures  have  been  noted  in  con- 
sequence of  insufficient  bulk  of  material.  There  can  be  no  argu- 
ment against  deepening  the  cavity  to  the  full  extent  of  the  fissure 
from  the  fact,  as  already  stated,  that  wherever  a  fissure  exists  there 
is  no  binding  strength  to  the  tooth  throughout  its  extent.  The 
certainty  of  determining  definitely  just  when  the  bottom  of  a 
fissure  is  reached  is  sometimes  rendered  difficult  on  account  of  the 
fine  particles  of  tooth-tissue  from  the  drill  filling  the  deepest  por- 
tion of  the  fissure  and  hiding  it  from  view.     This  may  readily  be 


4 

CLASSIFICATION    AIs^D    PREPAKATIOX    OF    CAVITIES.  137 

overcome  by  flooding  the  cavity  with  one  of  the  essential  oils, 
which  will  cause  the  fissure  to  immediately  show  up  dark  and  pre- 
sents its  entire  outline. 

The  width  of  the  cavity  bucco-lingually  or  mesio-distally  in  the 
decayed  portion  must  be  great  enough  to  insure  strong,  well-sup- 
ported walls,  while  in  the  fissured  portion  it  must  be  governed 
somewhat  by  the  extent  of  the  sulcus  leading  down  to  the  fissure. 
The  minimum  width  in  any  case  should  be  not  less  than  one  and 
one-half  millimeters.  The  mistake  of  leaving  too  narrow  a  cavity 
relates  to  the  difficulty  of  readily  securing  adaptation  and  density 
of  gold  in  a  constricted  crevice,  besides  the  important  factor  of 
pro\'iding  for  a  sufficient  bulk  of  filling-material  to  represent  con- 
sideralile  strength  on  all  surfaces  which  are  subjected  to  continued 
usage. 

Technique. — All  overhanging  walls  may  be  broken  down  with 
shai*p  chisels,  and  the  fissures  opened  with  drills  as  already  de- 
scribed. The  cavity  may  be  cut  to  form  with  an  inverted  cone  bur 
placed  with  its  end  looking  toward  the  pulp  and  carried  laterally 
to  the  extent  required.  In  cases  difficult  of  approach  with  the 
straight  hand-piece,— particularly  on  the  lower  teeth  and  the  upper 
teeth  of  the  left  side, — the  bur  may  be  used  in  the  right-angle  hand- 
piece. AVhere  the  decay  is  extensive  the  softened  dentine  should 
be  removed  with  spoon  excavators  to  avoid  unnecessary  pulp-expos- 
ure. The  enamel-margins  may  be  beveled  with  a  round  bur. 
Those  cavities  are  cut  to  form  very  expeditiously,  provided  the 
operator  uses  sharp  l)urs  and  goes  straight  to  his  work  with  a  defi- 
nite idea  in  his  mind  as  to  the  required  outline  and  form  of  the 
cavity  before  he  begins  cutting. 

General  Considerations. 

Of  all  filling-operations  in  the  mouth  these  should  prove  the 
most  permanent  and  satisfactory  if  properly  performed.  There  is 
little  likelihood  of  a  recurrence  of  decay  around  such  fillings  unless 
the  operator  has  left  imperfections  in  his  work  which  would  invite 
failure  under  any  circumstances.  The  wear  and  tear  upon  occlusal 
fillings  is  sometimes  great,  but  it  is  confidently  believed  that  with 


138  prijstciples  and  peactice  of  filling  teeth. 

the  plan  of  anchorage  here  outlined  ample  provision  is  made  for 
sustaining  the  filling  against  severe  usage.  The  flat  base  to  the 
cavity  secures  immunity  from  movement,  and  the  perpendicular 
walls  leave  no  overhanging  enamel  to  be  broken  down.  The 
obliteration  of  fissures  results  in  improved  form  to  the  surface  and 
precludes  the  possibility  of  micro-organisms  finding  a  habitat  in 
this  region.  Operations  here  as  elsewhere  must  be  carefully 
planned  and  executed  throughout,  but  the  results  on  occlusal  sur- 
faces are  never  so  much  in  doubt  as  they  would  seem  to  be  in  other 
localities. 

The  Treatment  of  Softened  Dentine  in  Deep-Seated  Cavities. 

In  the  preparation  of  cavities  the  operator  often  encounters  a 
problem  in  the  presence  of  a  large  mass  of  decalcified  or  partially 
decalcified  dentine  in  the  bottom  of  a  cavity  lying  over  the  pulp. 
The  treatment  of  this  softened  dentine  is  a  subject  that  has  long- 
engaged  the  attention  of  operators  and  writers  on  dental  topics, 
and  the  concensus  of  opinion  seems  in  the  past  to  have  been  favor- 
able to  the  retention  of  a  considerable  portion  of  the  decalcified 
tissue  for  the  purpose,  as  stated,  of  affording  protection  to  the 
pulp.  It  has  been  argued  that  the  pulp  will  accept  more  kindly 
this  sort  of  protection  than  it  will  the  presence  of  any  foreign 
material  in  the  nature  of  filling  or  pulp-capping.  Some  writers 
have  even  advanced  the  theory  that  the  softened  dentine  would 
take  on  a  hardening  process  and  become  recalcified  when  left  in  the 
cavity  under  these  conditions,  and  protected  from  further  external 
irritation  by  a  filling. 

Without  stopping  to  go  into  the  histological  process  of  tooth- 
building  and  the  pathological  process  of  tooth-disintegration,  it  is 
safe  to  assume  that  tooth-tissue  is  not  amenable  to  any  such  a  law 
as  would  account  for  the  recalcification  of  dentine  once  decalcified, 
and  the  sooner  this  idea  is  dismissed  from  the  minds  of  our  opera- 
tors the  better  it  will  be  for  their  patients.  From  the  closest  clini- 
cal observation  of  thoughtful  men,  and  from  recent  investigations 
into  the  penetrating  effects  of  caries  of  the  teeth,  it  would  seem  to 
be  a  serious  menace  to  leave  any  considerable  quantity  of  decalci- 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES.  139 

fied  dentine  nnder  a  filling.     Miller  has  shown  that  the  tubuli  of 
dentine  are  packed  with  micro-organisms  far  in  advance  of  the 
actual  breaking  down  of  the  tissue,  and,  more  re- 
eentlv.  Dr.  J.  Leon  Williams  has  presented  to  us  a 

<■  _  r  lO.   5o. 

revelation  in  the  far-reaching  effects  of  caries.  On 
page  289  of  the  Dental  Cosmos  for  April,  1897,  hei 
presents  a  photograph  of  which  Fig.  83  is  a  fair  repre-* 
sentation,  showing  how  a  tooth  may  be  affected  bv 
the  acid  of  caries  to  a  depth  beyond  the  enamel, 
and  reaching  very  .nearly  to  the  pulp  without  any 
serious  surface  indication.  The  tooth  was  one  in 
which  ''there  was  not  a  trace  of  a  cavity  to  be  seen  on  the  external 
surface."  Presumably  an  exploring  instrument  might  have  been 
passed  over  the  enamel  without  detecting  any  imperfection,  and 
yet  the  acid  formed  by  the  mass  of  micro-organisms  lodged  upon 
the  surface  had  so  affected  the  tooth-tissue  as  to  dissolve  out  the 
cement-substance  between  the  rods  of  enamel,  leaving  minute 
canals  down  which  the  acid  traveled  to  form  a  perceptible  cavity  at 
the  junction  of  the  enamel  and  dentine  and  also  to  extend  its  soften- 
ing influence  some  distance  into  the  dentine  in  the  direction  of  the 
pulp. 

Here  is  an  object  lesson  to  set  even  the  most  careless  operator  to 
thinking.  If  the  acid  of  decay  may  affect  tissue  to  the  depth  indi- 
cated Avithout  any  perceptible  external  evidence,  what  must  be  the 
condition  of  the  dentine  covering  the  pulp  when  the  process  of  de- 
cay has  gone  on  so  far  as  to  cause  a  complete  disintegration  of  the 
enamel  and  an  extensive  cavity  into  the  dentnie^  We  can  no 
longer  trifle  with  a  disease  which  projects  its  baneful  influence  so 
far  in  advance  of  any  ocular  manifestation. 

Let  us  study  briefly  the  nature  of  this  decalcified  tissue  which 
we  are  taught  to  leave  under  our  fillings.  It  has  in  large  part 
been  disorganized;  it  is  packed  with  micro-organisms  and  infil- 
trated with  poisons.  If  we  seal  it  under  a  filling  we  have  confined 
within  the  tooth  just  so  much  of  a  menace  to  the  life  and  comfort 
of  the  pulp.  It  will  not  do  to  say  that  the  micro-organisms  thus 
inclosed  are  rendered  harmless  on  account  of  cutting  off  their  out- 


140  PKINCIPLES    AND    PKACTICE    OF    FILLING    TEETH. 

side  sustenance  and  allowing  them  to  die.  A  mass  of  dead  micro- 
organisms is  by  no  means  inert.  In  fact,  scientists  are  telling  us 
that  from  the  dead  bodies  of  micro-organisms  come  the  most  viru- 
lent poisons.  J^either  will  it  do  to  assume  that  by  the  application 
of  an  antiseptic  to  the  cavity  we  overcome  the  difficulty.  We  may 
destroy  more  or  less  perfectly  the  micro-organisms  in  the  dentine, 
but  we  are  not  at  all  certain  of  thereby  destroying  the  poisons. 
In  experimental  work  micro-organisms  are  killed  with  chemical 
agents,  and  then  from  the  mass  thus  destroyed  the  poisons  are 
extracted.  It  would  seem  to  be  a  fruitful  field  of  research  for  some 
scientist  to  determine  the  kind  of  agent  required  to  destroy  the 
micro-organism  and  at  the  same  time  neutralize  its  poison. 

But  what  concerns  us  most  in  the  consideration  of  the  present 
subject  is  that  by  following  the  generally  accepted  teaching  of  the 
day  in  the  management  of  decalcified  dentine  we  are  simply  confin- 
ing in  intimate  proximity  to  the  pulp  a  mass  of  material  which  is 
peculiarly  calculated  to  poison  the  pulp  to  death.  And  this  is 
precisely  what  occurs  in  many  of  those  vague  cases  where  the 
pulp  has  '^unaccountably"  died  under  a  filling  without  an  exposure. 
The  greatest  surprise  is  that  more  pulps  have  not  died  from  this 
treatment,  and  it  is  accounted  for  only  on  the  ground  that  pulps 
are  sometimes  exceedingly  tenacious  of  life,  and  protect  them- 
selves against  the  inroads  of  the  poisonous  process  by  throwing 
out  a  deposit  of  secondary  dentine.  Even  in  those  cases  where  the 
pulp  finally  triumphs  over  the  evil  influence,  the  operation  of  fill- 
ing is  quite  frequently  succeeded  by  an  extended  period  of  sensi- 
tiveness which  is  the  direct  result  of  the  irritating  influence  of  the 
infiltrated  dentine.  In  almost  every  instance  where  softened  den- 
tine is  left  in  the  cavity  as  a  source  of  pulp  protection,  or  to  prevent 
shock  from  thermal  changes,  it  defeats  the  very  object  for  which  it 
was  left.  This  mass  of  tissue  is  exceedingly  irritable.  It  is  more 
sensitive  to  impressions  of  all  kinds,  whether  thermal,  chemical,  or 
mechanical,  than  is  normal  dentine.  It  would  therefore  seem 
theoretically  that  the  less  we  left  of  this  infected  tissue  under  a 
filling  the  more  comfortable  would  the  tooth  remain  after  the 
operation,  and  this  very  fact  is  amply  borne  out  by  clinical  observa- 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES.  141 

tion.  Ill  a  somewhat  close  study  of  this  question  it  has  been  noted 
that  in  those  cases  where  a  radical  removal  of  all  softened  dentine 
has  been  effected  there  is  seldom  any  complaint  of  subsequent 
sensitiveness. 

This  does  not  imply  that  we  must  carelessly  expose  pulps  by 
wantonly  slashing  away  at  every  cavity  that  presents.  No  opera- 
tor should  expose  a  pulp  if  it  can  be  safely  avoided.  In  working 
around  a  pulp  under  these  conditions,  as  has  already  been  inti- 
mated, a  spoon-shaped  excavator  should  be  used  to  avoid  needless 
exposure.  The  excavator  should  be  very  thin  and  sharp,  so  as  to 
peel  up  the  leathery  dentine  with  the  utmost  delicacy  and  the  ex- 
penditure of  very  little  force. 

The  rules  to  govern  the  operator  in  the  management  of  decalci- 
fied dentine  may  be  summarized  as  follows:  Kemove  thoroughly 
all  decalcified  tissue  in  every  instance  where  its  removal  will  not 
result  in  exposure  of  the  pulp.  In  those  cases  where  it  extends  to 
the  pulp  remove  all  that  can  safely  be  done  short  of  actual  ex- 
posure, and,  if  large  masses  of  decomposing  tissue  surround  any 
portion  "of  the  pulp,  remove  even  if  it  causes  exposure.  The  pulp 
will  be  safer  under  a  capping  of  foreign  material  than  when  sub- 
jected to  the  influence  of  this  infected  and  poisonous  mass. 
Stained  dentine  is  not  necessarily  infected  dentine.  If  hard  and 
flint-like  it  may  be  allowed  to  remain,  even  if  slightly  discolored. 

While  the  exact'  results  of  the  application  of  medicaments  to 
decalcified  dentine  may  be  as  yet  somewhat  undetermined,  it  would 
seem,  with  our  present  knowledge  on  the  subject,  to  be  a  wise 
precaution  to  flood  all  cavities  containing  any  such  tissue  with  an 
antiseptic  previous  to  filling.  We  must  also  protect  the  pulp  from 
impingement  in  those  cases  where  the  partition  between  the  cavity 
and  the  pulp  is  so  thin  as  to  be  compressible  under  the  force  of 
impact  by  the  plugger  in  condensing  a  metal  filling,  or  where  there 
seems  to  be  danger  from  thermal  impressions.  For  this  purpose 
a  non-irritating  cement  is  indicated  as  an  intermediate  between  the 
filling  and  the  pulpal  wall,  but  this  cement  must  not  be  built  up  in 
sMch  bulk  as  to  render  the  metal  filling  too  thin  for  strength. 


142  PEINCIPLES    AND    PKACTICE    OF    FILLING    TEETH. 

Hypersensitive  Dentine. 

This  is  a  subject  which  has  been  more  or  less  prominently  before 
the  profession  ever  since  teeth  began  to  be  filled,  and  yet  it  would 
sometimes  seem  to  be  little  nearer  a  solution  of  the  problem  than 
when  it  w^as  first  discussed.  This  is  partly  because  there  are  so 
many  varying  aspects  of  the  question,  and  because  no  sovereign  or 
universal  remedy  can  ever  be  suggested  by  which  uniform  results 
may  be  obtained;  but  possibly,  more  than  all  else,  because  the  very 
thing  most  essential  to  success  in  meeting  the  trouble  is  something 
that  cannot  well  be  taught.  It  relates  to  a  quick  perception  on 
the  part  of  the  operator  as  to  the  real  difficulty  with  each  case 
which  presents,  and  to  the  most  active  ingenuity  in  meeting  the 
particular  issue  involved.  In  many  instances  it  would  seem  to  be 
the  dentist  who  needed  treatment  instead  of  the  dentine.  In 
others  the  patient  requires  operating  on  in  advance  of  the  tooth. 

To  present  this  subject  in  anything  approaching  a  systematic 
order,  it  will  be  necessary  to  classify  somewhat  the  conditions 
which  may  confront  the  operator.  These  conditions  relate  to  the 
varying  temperaments  of  patients,  and  to  the  differences  in  char- 
acter of  sensitive  teeth.  Patients  require  the  closest  study  in  order 
to  know  how  best  to  approach  them  to  dispel  the  common  dread  of 
the  dental  chair,  and  no  operator  is  suited  to  the  practice  of  den- 
tistry who  ignores  this  important  feature  of  his  work.  It  has  been 
too  long  a  crying  disgrace  to  dentistry  to  permit  the  impression  to 
prevail  among  all  classes  that  dental  operations  are  necessarily  so 
very  painful.  Some  of  the  old-time  heroic  operators  (blessed  be 
their  memory)  are,  in  this  one  particular,  blamable  that  they  too 
often  entirely  ignored  the  sensibilities  of  their  patients,  and  treated 
them  as  if  they  were  mere  blocks  of  wood.  We  of  to-day  are  reap- 
ing the  results  of  some  of  this  early  sowing  in  the  almost  universal 
dread  with  which  patients  approach  the  dental  chair,  owing  largely 
to  the  traditional  story  of  its  tortures.  In  the  modern  dental  prac- 
tice, properly  conducted,  there  is  little  to  justify  this  dread,  and 
the  dentists  of  to-day  should  do  all  in  their  power  to  overcome  the 
impressions  formed  by  past  years  of  mismanagement. 

In  studying  the  characteristics  of  our  patients  in  this  regard  it 


CLASSIFICATIOIf    AHU)    PREPARATION    OF    CAVITIES.  143 

might  be  possible  to  make  many  minute  classifications  as  to  con- 
duct and  temperament,  but  for  present  purposes  a  more  general 
consideration  must  sufiice. 

First  as  a  class  may  be  noted  those  of  a  highly-wrought,  nervous 
temperament,  who  are  by  nature  sensitive  to  impressions  of  all 
kinds,  whether  physical  or  mental.  This,  when  augmented  by 
environment  or  occupation,  creates  a  condition  which  calls  for  the 
keenest  perception  on  the  part  of  the  dentist,  both  as  to  manage- 
ment of  the  patient  and  manipulation  of  the  teeth.  They  are 
usually  professional  men  or  women, — artists,  musicians,  sculptors, 
or  literary  people, — and,  fortunately  for  us,  they  are  generally  indi- 
viduals of  a  high  order  of  intelligence.  They  are  quick  in  their 
perceptions  and  are  appreciative  of  skillful  service.  jSTo  dentist  of 
mediocre  attainments  need  hope  for  an  extended  practice  among 
this  class,  and  yet,  if  managed  by  a  master  hand,  they  prove  a  most 
desirable  clientele.  The  essentials  in  meeting  these  patients  relate 
to  a  thorough  mastery  of  the  minutest  details  of  the  work  in  hand, 
and  a  quiet  but  rapid  execution  of  all  manipulative  procedures. 
There  must  be  no  false  movements,  and  no  lapses  of  the  closest 
application.  To  accomplish  the  greatest  good  all  work  must  be 
done  on  the  high-pressure  principle.  A  patient  like  this  will  bear 
to  be  hurt  for  one  short  moment  provided  something  definite  be 
accomplished  in  that  moment,  but  will  not  tolerate  unskillful  put- 
tering. E^-ery  line  of  procedure  must  be  carefully  studied  by  the 
operator  in  advance,  so  that  he  knows  precisely  what  he  is  going 
to  do  before  he  attempts  to  do  it.  Any  awkward  fumbling  in  the 
manipulation  is  instantly  recognized  by  the  patient,  and  confidence 
is  to  that  extent  destroyed.  The  utmost  delicacy  of  touch  should 
be  cultivated,  and  this  complemented  by  firmness  of  force  wherever 
force  is  indicated.  Short  sittings  must  be  assigned,  and  the  great- 
est possible  measure  of  accomplishment  attained  during  the  time 
the  chair  is  occupied.  In  brief,  this  type  of  individual  demands 
of  a  dentist  the  exercise  of  his  keenest  wits,  and  to  operate  to 
the  best  advantage  he  must  operate  on  a  tension  keyed  to  the 
highest  pitch.  It  is  therefore  well  that  all  our  patrons  are  not 
of  this  variety,  and  yet,  as  has  been  intimated,  they  prove  a  savor- 


144  PKIK'CIPLES    AND    PKACTICE    OF    FILLING    TEETH. 

ing  lump  to  tlie  rank  and  file  and  are  in  many  ways  a  desirable 
class.  Tliej  stimulate  an  operator  to  his  best  achievements,  and 
reward  him  with  an  intelligent  appreciation  of  all  that  he  accom- 
plishes for  them. 

Another  class  of  patients  consist  of  large,  robust,  healthy  indi- 
viduals who  are  by  nature  cowardly  when  it  comes  to  the  infliction 
of  physical  discomfort.  They  may  be  brave  enough  about  other 
affairs  of  life,  but  it  would  sometimes  seem  that  the  larger  they  are 
in  physical  proportions  the  smaller  they  are  in  courage  to  take  the 
dental  chair.  There  is  no  moral  suasion  that  can  be  used  on  these 
people  to  make  good  patients  of  them.  The  only  line  of  procedure 
is  to  avoid  as  far  as  possible  giving  pain  by  the  use  of  obtundents, 
or  by  employing  plastic  fillings  and  temporizing  to  keep  the  teeth 
comfortable,  with  the  hope  that  eventually  we  may  in  some  degree 
overcome  their  dread  sufiiciently  to  accomplish  more  permanent 
results.  If  we  undertake  anything  like  thorough  work  at  the  out- 
set, we  simply  drive  them  away  from  the  dental  office  to  allow  the 
teeth  to  decay  past  all  recovery.  Then  when  toothache  assails 
them  they  seek  out  some  dentist  who  gives  gas,  and  that  is  the  end 
of  that  chapter. 

Another  class  relates  to  those  effeminate,  irresponsible  indi- 
viduals who  have  no  stamina  of  any  kind,  physical  or  mental,  and 
who  require  a  strong  guiding  hand  to  control  them  in  any  emer- 
gency of  life.  They  are  usually  forced  to  go  to  the  dentist  either 
by  pain  or  by  the  admonition  of  friends,  and  their  successful  man- 
agement calls  for  a  rare  combination  of  gentleness  and  firmness. 
They  must  of  course  be  assured  that  the  dentist  will  not  hurt 
them  more  than  is  absolutely  necessary,  but  they  should  also  be 
given  to  understand  that  they  must  nerve  themselves  against  any 
pain  that  is  necessary.  A  dentist  should  never  be  harsh  with  any 
patient,  but  with  this  particular  class  it  is  sometimes  salutary  to  be 
stern  and  to  permit  of  no  trifling.  If  much  sternness  is  demanded 
during  an  operation,  it  should  invariably  be  tempered  before  the 
patient  vacates  the  chair  with  the  kindest  possible  tone  of  voice,  to 
the  end  that  the  patient  leaves  the  office  with  the  conviction  that 
the  dentist  is  kind  of  heart  and  is  severe  only  for  the  patient's  good. 


CLASSIFICATIOX    AXD    PREPARATION    OF    CAVITIES.  145 

A  series  of  dental  operations  for  an  individual  of  this  type  often 
proves  of  the  utmost  disciplinary  benefit,  provided  the  operator  is 
an  acute  reader  of  character  and  knows  just  when  to  be  firm  and 
when  to  be  gentle. 

He  should  be  quick  to  detect  the  difference  between  simulated 
pain  and  real  pain,  from  the  fact  that  these  patients  are  much  given 
to  protesting  even  when  there  is  no  occasion  for  it.  A  simple 
pressure  of  an  excavator  on  the  enamel  of  a  sound  tooth  is  as 
likely  to  cause  them  to  flinch  as  if  a  mass  of  sensitive  dentine  were 
being  removed,  and  no  self-respecting  operator  will  long  allow 
himself  to  be  made  the  victim  of  this  kind  of  folly.  He  should 
have  the  issue  out  with  them  immediately  on  the  detection  of  such 
imposition,  and  give  them  to  understand  that  he  is  neither  to  be 
deceived  nor  trifled  with.  But  the  moment  it  becomes  necessary 
to  give  real  pain  he  should  be  the  very  essence  of  gentleness  and 
forbearance,  and  do  all  in  his  power  to  help  the  patient  over  the 
painful  points.  In  this  way  he  will  not  only  prevent  imposition  in 
the  future,  but  will  establish  confidence  in  the  mind  of  the  patient 
that  he  is  solicitous  only  for  his  patron's  welfare.  Absolute 
honesty  of  conviction  and  conduct,  together  with  tact  in  its  fulfill- 
ment, is  the  keynote  of  success  with  these,  as  in  fact  with  all  other 
patients. 

The  management  of  children  in  the  dental  office  is  another  con- 
sideration worthy  of  the  closest  study.  A  child  never  should  be 
given  pain  if  possible  on  the  occasion  of  its  first  visit  to  the  dentist. 
In  fact,  the  infliction  of  pain  should  be  as  largely  avoided  as  may 
be  till  a  feeling  of  harmony  and  confidence  has  been  established 
between  the  little  patient  and  the  operator.  A  child  should  be 
received  in  the  operating-room  with  a  cheery  smile,  as  if  the 
affairs  of  the  world  were  very  bright  on  that  particular  occasion, 
and  that  a  visit  to  the  dental  office  was  not  such  a  terribly  serious 
thing  after  all.  Unfortunately,  children  usually  come  to  the  den- 
tist with  more  or  less  apprehension,  owing  to  the  traditional  table 
talk  about  the  horrors  of  the  dental  chair.  It  is  the  prime  function 
of  The  dentist  to  dispel  this  idea,  and  he  who  lias  kindness,  tact, 
an<l  good  judgment  can  work  wonders  in  tliis  direction  on  that 

10 


146  PKINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

momentous  first  visit.  But  he  must  liave  a  love  of  children  in- 
herent in  his  heart  or  he  cannot  hope  to  succeed.  He  who  does 
not  love  children  would  better  direct  them  to  some  one  who  does, 
because  of  a  certainty  they  will  prove  a  constant  source  of  annoy- 
ance to  him,  and  he  will  accomplish  little  else  with  them  than  to 
increase  their  dread  and  distaste  of  dental  operations. 

A  child  should  never  be  deceived  by  a  dentist  under  any  pretext 
whatever,  and  yet  it  is  not  well  to  make  prominent  the  fact  that  it 
is  going  to  be  necessary  to  inflict  pain.  The  dentist  should  lead 
gradually  up  to  any  painful  operation  by  a  series  of  dextrous  and 
careful  manipulations  about  the  teeth,  and  a  running  talk  with  the 
patient  upon  the  contingencies  of  the  case  from  a  child's  point  of 
view.  The  thing  of  first  importance  is  to  establish  confident 
and  cordial  relations  with  the  patient,  and  when  this  is  once  at- 
tained the  operator  can  accomplish  really  wonderful  results,  even 
upon  the  youngest  child.  Tact,  kindness,  the  alleviation  of  pain 
when  the  patient  is  suffering,  lack  of  deception,  and  short  sittings, 
all  harmonize  into  the  successful  management  of  children's  teeth. 

If  the  control  of  the  different  classes  of  patients  herein  briefly 
outlined  is  studied,  the  problem  of  the  sensitive  dentine  is  many  de- 
grees more  than  half  solved;  in  fact,  it  would  sometimes  seem  as  if 
this  bugbear  were  greatly  exaggerated  by  the  profession,  A  care- 
ful observation  of  the  causes  which  lead  the  average  patient  of 
to-day  to  dread  the  dental  chair  in  a  properly  conducted  practice 
will  reveal  the  fact  that  it  is  as  much  the  concomitant  annoyances 
-of  the  rubber  dam,  the  separator,  the  mallet,  the  use  of  disks  or 
finishing  strips,  the  grating  of  excavators,  or  the  vibration  of  rotary 
instruments,  as  it  is  the  infliction  of  any  real  pain  in  the  cutting  of 
sensitive  dentine.  And  yet  there  are  many  unmistakable  cases 
of  actual  hypersensitiveness  that  must  be  recognized  and  dealt 
with. 

The  treatment  of  these  cases  relates  to  proper  instrumentation 
and  proper  medication, — the  former  fully  as  important  as  the 
latter.  The  dextrous  use  of  instruments  will  reduce  the  number  of 
cases  requiring  medication  to  a  very  narrow  limit,  and  it  is  strongly 
urged  that  a  most  careful  study  be  made  of  the  manner  of  ap- 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES.  147 

proachmg  hypersensitive  dentine  so  as  to  remove  it  with  the  least 
possible  discomfort. 

Cavities  may  be  divided  more  or  less  perfectly  into  classes,  each 
class  presenting  its  own  peculiarities  of  sensitiveness,  and  suggest- 
ing the  method  of  treatment  best  suited  for  it.  A  large  class  con- 
sists of  those  cases  where  there  is  a  mass  of  softened  dentine  nearly 
:filling  the  cavity,  with  much  overhanging  enamel.  If  an  instru- 
ment is  thrust  into  this  leathery  mass  at  almost  any  point  it  is  sensi- 
tive. If  there  is  any  manipulation  of  it  along  the  surface  it  gives 
pain.  The  first  thing  to  do  is  to  break  down  all  overhanging 
enamel,  so  that  the  dentine  lies  as  fully  exposed  as  may  be  before 
any  attempt  is  made  to  remove  it.  Then,  with  a  thin-bladed  exca- 
vator, whetted  keenly  sharp,  the  whole  mass  should  be  removed  as 
■completely  as  possible  with  one  sweep.  This  can  ordinarily  be 
done  with  little  pain  if  the  blade  of  the  excavator  be  sunk  at  one 
side  of  the  leathery  mass  to  its  depth,  and  the  mass  rolled  out. 
The  tissue  immediately  under  this  softened  layer  is  usually  not  so 
sensitive  as  the  surface,  and  the  remaining  cutting  to  give  form  to 
the  cavity  is  seldom  appreciably  painful.  But,  in  case  there  is  sen- 
sitiveness, it  can  be  controlled  by  dehydrating  the  tissue  with  alco- 
hol, followed  by  warm  air.  If  the  rapid  dehydration  causes  pain 
it  should  be  preceded  by  ninety-five  per  cent,  carbolic  acid,  after 
which  the  cavity  can  be  dried  with  little  discomfort. 

In  the  application  of  any  medicament  to  a  cavity  the  fact  should 
be  made  prominent  to  the  patient  that  the  drug  is  being  used  for 
the  purpose  of  relieving  the  pain.  This  of  itself  reassures  the  pa- 
tient, and  is  often  of  more  benefit  in  a  psychological  way  than  is 
the  specific  action  of  the  drug. 

Another  class  of  cavity  calling  for  treatment  peculiar  to  the 
case  in  hand  consists  of  those  shallow  oval  cavities,  particularly  on 
the  labial  or  buccal  surfaces,  where  there  is  little  softened  dentine, 
but  merely  a  corroded  and  reasonably  hard  surface  to  the  cavity. 
Most  of  the  cutting  must  be  done  in  comparatively  firm  tissue,  for 
the  purpose  of  giving  retentive  form  to  the  cavity  and  to  secure 
perfect  margins.  These  cavities  are  much  dreaded  by  dentists  on 
account  of  their  traditional  sensitiveness,  but  by  a  careful  observa- 


148  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

tion  it  will  be  found  that  with  very  many  of  them  the  sensitiveness 
exists  only  on  the  surface.  The  first  touch  is  the  worst.  If,  when 
the  rubber  dam  is  applied  and  the  cavity  dried,  the  operator  will 
take  a  sharp  inverted  cone  bur,  as  already  advised  for  forming- 
these  cavities,  and,  with  the  engine  revolving  rapidly,  place  the  end 
of  the  bur  in  the  deepest  portion  of  the  cavity,  and  just  at  that 
moment  speak  to  the  patient  in  a  reassuring  tone  of  voice,  and 
while  speaking  at  once  penetrate  this  outer  sensitive  crust  with 
the  bur,  the  worst  of  that  cavity  preparation  is  over.  The  bur 
may  then  be  carried  laterally,  its  end  to  the  full  depth  of  the  cavity 
and  cutting  with  its  sides,  causing  little  pain.  The  active  cutting 
in  the  deep  portion  of  the  cavity  is  less  painful  than  would  be  the 
slightest  manipulation  on  the  surface.  The  surface  should  there- 
fore be  left  alone  as  largely  as  possible  till  the  sides  of  the  bur  have 
undermined  it  in  advance.  In  the  successful  management  of  these- 
cases  there  must  be  no  hesitation  and  no  half  measures.  The 
operator  must  know  definitely  what  he  is  going  to  do,  and  then  do- 
it with  the  greatest  dispatch  and  precision.  It  requires  a  masterly,, 
vigorous  hand,  wielded  with  the  utmost  delicacy. 

Sometimes  the  surface  sensitiveness  of  these  cavities  may  be 
greatly  reduced  by  medication  and  desiccation.  For  this  purpose 
carbolic  acid,  followed  by  alcohol  evaporated  with  warm  air,  seems 
to  give  the  best  results  with  the  least  accompanying  discomfort. 
The  application  of  drugs  which  cause  more  pain  on  contact  with 
the  dentine  than  would  the  preparation  of  the  cavity  itself  should 
be  discontinued,  unless  for  those  exceptional  individuals  who  seem 
to  prefer  any  kind  of  pain  rather  than  pain  given  by  an  instrument. 

With  very  many  cavities  it  will  be  found  that  the  sensitiveness- 
is  confined  to  one  or  two  small  areas,  which  if  dextrously  under- 
mined or  cut  through  quickly  will  solve  the  problem  in  short  order. 
When  an  operator  discovers  in  a  cavity  one  of  these  sensitive 
points  he  should  avoid  manipulating  it,  unless  with  a  definite 
attempt  at  its  complete  removal. 

The  last  class  of  cavities  for  consideration  relates  to  those  occa- 
sional cases  where  the  teeth  are  in  an  unmistakably  hypersensitive 
condition,  where  the  slightest  pressure  upon  a  cavity  results  in^ 


CLASSIFICATION    AND    PKEPAKATION    OF    CAVITIES.  149 

pain,  and  where  anything  like  thorough  manipulation  is  out  of  the 
question.  There  is  one  of  two  courses  to  pursue:  either  to  numb 
the  sensibilities  of  the  tooth  by  cataphoresis,  with  all  of  its  con- 
comitant paraphernalia,  its  consumption  of  time,  its  accidents, 
and  its  as  yet  undetermined  ultimate  results,  or  to  employ  as  a 
temjDorary  expedient  till  the  sensitiveness  subsides  some  filling- 
material  such  as  cement,  which  may  be  used  without  the  thorough 
preparation  of  the  cavity  required  for  the  metals. 

Sometimes  one  course  is  indicated  and  sometimes  the  other,  but 
in  the  large  percentage  of  cases  it  will  be  found  better  to  make  use 
of  temporary  fillings  to  tide  the  teeth  over  the  sensitiveness,  rather 
than  to  follow  the  general  employment  of  cataphoresis.  This 
latter  process,  unless  simplified  far  beyond  its  present  complica- 
tions, is  indicated  only  in  exceptional  and  desperate  cases,  where 
hope  for  relief  in  no  other  way  is  possible. 

In  the  use  of  cement  for  the  sealing  of  cavities  temporarily,  as 
just  advised,  the  common  error  is  made  of  allowing  it  to  remain 
too  long,  till  it  is  so  disintegrated  as  to  defeat  the  object  for  which 
it  was  used.  If  a  cement  filling  be  placed  in  a  very  sensitive  cavity 
so  as  to  perfectly  seal  it  from  external  irritants,  and  allowed  to 
remain  from  three  to  four  months,  it  will  be  found  on  removal  that 
the  cavity  can  be  prepared  properly  with  little  pain.  As  much  of 
the  decay  as  possible  should  be  removed  from  the  cavity  before  the 
cement  is  inserted,  and  when  the  cement  is  to  be  drilled  out  the 
rubber  dam  should  be  applied  and  the  cavity  kept  free  from  mois- 
ture till  prepared  as  desired.  In  those  cases  where  it  seems  impos- 
sible to  remove  the  decay  in  the  first  instance  it  is  often  advantage- 
ous to  seal  a  pledget  of  cotton  saturated  with  the  oil  of  cloves  in  the 
cavity  for  three  or  four  days,  when  the  decay  can  ordinarily  be 
rolled  out  of  the  cavity  with  sharp  excavators. 

The  whole  question  of  the  management  of  sensitive  dentine, 
except  in  the  rare  instances  just  indicated,  resolves  itself  to  the  fol- 
lowing summary:  Manipulative  skill  on  the  part  of  the  operator, 
tact  in  knowing  how  to  control  the  different  temperaments  among 
our  patients,  and  the  invariable  use  of  the  keenest,  sharpest  instru- 
ments. 


150  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

CHAPTEK     VI. 

FILLING-MATERIALS. 

A  PROPER  consideration  of  the  filling-materials  in  use  at  the 
present  time  leads  us  at  once  to  the  conviction  that  we  have  no 
ideal  material  with  which  to  fill  teeth.  We  have  materials  which 
answer  the  purpose  reasonably  well  under  certain  conditions,  but 
no  material  which  answers  well  under  all  conditions.  It  is  there- 
fore important  that  in  the  consideration  of  this  question  we  studj 
somewhat  carefully  the  characteristics  of  th-e  different  materials 
and  the  indications  for  or  against  their  use  under  the  varying  con- 
ditions found  in  the  mouth.  This  must  be  done  with  the  fact 
constantly  in  mind  that  no  rigid  or  invariable  rule  may  be  laid 
down  for  the  operator  to  follow  in  every  case  in  the  selection  of  his 
material.  He  must  exercise  his  best  judgment  on  the  basis  not 
only  of  expediency,  but  of  the  history  of  the  various  materiala 
under  long-continued  service. 

Gold  and  Its   Combinations. 

Of  all  the  materials  yet  introduced  for  filling  teeth,  gold  must 
be  acknowledged  the  peer.  When  properly  understood  and  prop- 
erly manipulated,  under  conditions  favorable  to  its  use,  it  is  one 
of  the  most  permanent  materials  we  possess.  It  is  imperious  in 
its  requirements,  as  are  all  things  worthy,  and  he  who  would  get 
the  most  from  its  use  must  adequately  acquaint  himself  with  its 
characteristics.  These  once  understood,  and  the  necessary  skill 
developed  to  master  the  details  of  its  manipulation,  the  operator  is 
equipped  with  a  material  which  is  more  reliable  than  any  other, 
and  more  definite  in  results. 

Its  chief  advantages  consist  in  the  fact  that  it  may  be  made  suf- 
ficiently hard  to  withstand  the  wear  of  mastication;  that  it  is  not 
acted  on  chemically  by  the  fluids  of  the  mouth  so  as  to  change  color 
or  disintegrate;  that  it  remains  stationary  in  form  when  properly 
condensed,  and  that  it  is  uniform  in  its  behavior  when  subjected  to 
uniform  methods  of  manipulation.     This  latter  quality  is  really  of 


riLLIXG-MATERIALS.  151 

much  greater  importance  than  a  superficial  consideration  would 
suggest.  It  enables  the  operator  to  attain  with  it  definite  results, 
year  after  year.  It  will  do  to-day  precisely  what  it  did  the  day 
before,  or  what  it  did  a  year  ago.  This  is  not  true  of  most  other 
filling-materials,  or  at  least,  if  it  is  true,  the  requirements  for  main- 
taining uniformity  in  the  others  are  vastly  more  intricate  and  not 
so  readily  comprehended  as  with  gold. 

"When  it  is  stated  that  uniform  results  may  always  be  obtained 
with  gold,  reference  is  made  solely  to  its  physical  behavior.  It  is 
not  intended  to  imply  that  teeth  are  uniformly  saved  by  its  use, 
even  when  it  is  manipulated  to  the  best  advantage.  There  are  ex- 
traneous factors  entering  into  the  salvation  or  loss  of  filled  teeth 
entirely  apart  from  the  intrinsic  merits  of  the  material  with  which 
they  are  filled,  and  gold  cannot  be  exempted  from  these  conditions. 
But  it  has  a  greater  range  of  qualities  entitling  it  to  respect  as  a 
saver  of  teeth  than  any  other  one  material,  and  its  thorough  under- 
standing should  be  the  aim  of  every  practitioner. 

Its  disadvantages  may  be  said  to  consist  chiefly  in  the  fact  that 
it  is  somewhat  exacting  in  its  demands  upon  the  operator;  that  it 
cannot  be  manipulated  successfully  under  moisture;  that  its  color 
renders  it  conspicuous  for  anterior  teeth,  particularly  in  individuals 
of  certain  types,  and  that  it  is  a  conductor  of  thermal  changes. 
Another  objection  which  must  be  considered  in  some  patients  is  the 
lengtli  of  time  necessary  for  its  insertion,  with  its  corresponding- 
tax  on  the  individual,  and  its  relative  cost;  though  the  fact  should 
be  strongly  noted  that  a  thorough  mastery  of  the  material  by  the 
operator  will  reduce  much  of  this  within  the  limits  of  tolerance. 

Ifor  must  the  claim  of  its  exacting  nature  be  held  in  too  high 
esteem  as  a  disadvantage.  This  very  requisite  on  the  part  of  gold 
has  done  more  than  any  other  one  thing  in  developing  the  skill  of 
the  dental  profession  to  its  present  standard  of  excellence.  Had  it 
not  been  for  gold,  or,  in  other  words,  had  all  our  filling-materials 
been  of  a  plastic  nature,  dentistry  never  would  have  developed  the 
brilliant  manipulators  who  have  graced  its  ranks.  Gold  is  the 
stimulative  astringent  of  the  dental  profession,  keeping  our  opera- 
tors keyed  up  to  the  highest  point  of  proficiency  by  reason  of  its 


152  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

imperious  demands  upon  their  ability.  A  good  gold-worker  is 
enabled  to  perform  all  other  kinds  of  dental  service  as  the  result 
of  his  skill  acquired  in  the  manipulation  of  gold,  and  this  sort  of 
training  has  been  the  saving  grace  of  dentistry. 

Too  many  sins  which  belonged  properly  elsewhere  have  been 
laid  at  the  door  of  gold.  Men  have  attempted  its  use  without  a 
sufficiently  developed  skill,  or  without  a  proper  understanding  of 
its  necessities.  They  have  ignored  its  physical  properties  and  its 
peculiar  demands.  Other  men  have  essayed  with  it  the  impossi- 
ble, and  then  attributed  their  failures  to  the  material,  thus  laying 
gold  unjustly  at  fault. 

The  fact  that  gold  cannot  be  successfully  used  under  moisture  is 
neither  an  unmixed  evil  nor  altogether  a  disadvantage,  when 
viewed  in  the  light  of  the  greatest  perfection  of  results  in  our 
work.  iSTo  filling,  of  whatever  material,  can  be  inserted  under 
moisture  as  perfectly  as  if  the  cavity  were  dry,  and  this  necessity 
of  gold  simply  increases  our  care  and  leads  to  greater  certainty  of 
results.  It  has  also  made  us  more  expert  in  maintaining  dryness 
of  teeth  to  be  operated  on. 

The  objection  of  color  is  a  real  one  in  many  instances,  and  the 
vulgar  display  of  gold  in  the  mouths  of  the  American  people  is 
greatly  to  be  deplored.  But  this  may  largely  be  overcome,  and  the 
artistic  sense  of  observers  less  seriously  offended  than  it  is  without 
an  abandonment  of  gold  in  the  anterior  teeth.  A  close  study  of 
the  question  Avill  reveal  the  fact  that  gold  is  much  more  objection- 
able in  some  mouths  than  in  others.  In  certain  individuals  a  well- 
finished  gold  filling,  beautifully  polished  without  being  burnished 
^so  as  to  glisten,  is  not  at  all  conspicuous,  even  in  an  incisor,  and  not 
an  offense  to  the  esthetic  taste  of  the  most  exacting.  In  other  in- 
dividuals a  gold  filling  in  the  anterior  part  of  the  mouth  is  at 
best  an  eyesore. 

The  difference  in  the  effect  of  gold  upon  the  appearance  of  indi- 
viduals  relates  principally  to  the  temperament  and  complexion  of 
the  patient,  as  well  as  to  an  esthetic  sense  on  the  part  of  the  opera- 
tor, which  may  enable  him  to  give  his  fillings  artistic  forms.  The 
latter  consideration  should  be  carefully  studied  by  every  operator, 


FILLIXG-MATEKIALS.  153 

to  the  end  that  gold  fillings  in  the  future  should  not  be  allowed  to 
offend  so  glaringly  as  in  the  past,  particularly  in  those  instances 
M'here  offense  is  not  necessary.  As  to  complexion,  it  will  be  found 
that  decided  blondes  will  tolerate  gold  in  their  anterior  teeth  with 
less  objection  than  will  brunettes.  In  fact,  the  color  of  gold  har- 
monizes so  well  "with  the  former  that  if  the  filling  is  well  inserted 
there  is  nothing  to  offend  the  eye  at  a  distance  of  several  feet. 
On  the  other  hand,  a  gold  filling  in  the  mouth  of  a  brunette  be- 
comes at  once  conspicuous  and  objectionable.  It  is  completely 
out  of  harmony  with  the  features,  and  should  never  be  tolerated 
except  under  circumstances  of  the  most  urgent  necessity.  This 
necessity  seldom  exists,  in  A^ew  of  the  fact  that  we  have  a  material 
at  hand  which  makes  a  filling  scarcely  discernible  in  these  cases  at 
a  distance  of  ordinary  conversation.  This  relates  to  a  combination 
of  gold  and  platinum  which,  under  its  proper  head,  will  be  con- 
sidered in  detail.  The  various  gradations  from  brunette  to 
blonde  may  be  met  with  gold  and  platinum  by  using  the  different 
numbers  as  they  come  to  us  from  the  manufacturer,  so  that  fillings 
may  be  made  which  will  not  be  conspicuous,  and  every  operator 
should  acquaint  himself  with  this  material. 

The  question  of  thermal  influence  under  gold  fillings  has  claimed 
much  attention  from  the  profession,  and  there  has  been  a  large 
degree  of  misconception  concerning  it.  Gold  has  been  credited 
with  more  mischief  in  this  particular  than  its  merits  warrant;  for, 
Avhile  tlie  material  itself  is  a  good  conductor,  it  can  be  used  in  the 
mouth  with  little  discomfort  and  little  danger,  provided  proper 
precautions  are  taken.  Gold  is  well  tolerated  even  in  large  cavi- 
ties, if  the  pulp  is  not  nearly  exposed,  or  if  there  is  not  hyper- 
sensitiveness  of  the  dentine.  In  the  former  case  the  pulp  should 
be  protected  by  an  intermediate  layer  of  cement  before  the  gold 
is  inserted,  and  in  the  latter  case  the  hypersensitiveness  should 
be  controlled  by  medication  previous  to  filling.  Probably  one  of 
the  best  agents  for  this  purpose  is  ninety-five  per  cent,  carbolic 
acid. 

One  important  factor  connected  with  this  question  of  thermal 
troulde  relates  to  a  condition  apart  from  the  filling  itself.     In  the 


154  PRIiSrCIPLES    AND    PKACTICE    OF    FILLING    TEETH, 

past,  the  profession  has  been  very  generally  advised  to  leave  in  the 
bottom  of  cavities  of  any  extent  a  portion  of  decalcified  dentine  as 
a  protection  to  the  pulp,  the  fallacy  of  which  has  already  been 
pointed  out.  Gold  has  frequently  been  severely  censured  when 
the  chief  factor  at  fault  in  the  case  has  been  the  presence  in  the 
cavity  of  a  hypersensitive  mass  of  decalcified  tissue  which  should 
have  been  removed  in  the  preparation  of  the  cavity. 

If  these  precautions  are  taken,  the  trouble  from  thermal  changes 
under  a  gold  filling  will  be  found  for  the  most  part  temporary, 
and  not  of  such  serious  import  as  has  usually  been  attributed 
to  it. 

The  indications  for  or  against  the  use  of  gold  in  filling  teeth 
relate  to  conditions  most  of  which  must  be  apparent  to  every  ob- 
servant operator.  It  should  be  used  in  all  cases,  if  possible,  where 
the  greatest  utility  and  the  greatest  permanence  are  expected  of  the 
operation.  It  should  not  be  used  where  the  conditions  are  such 
that  it  is  manifestly  impossible  to  accomplish  perfect  work  with  it. 
The  control  of  the  patient,  whether  young  or  old,  is  a  necessary 
concomitant  to  the  successful  use  of  gold.  It  should  not  be 
attempted  with  a  patient  upon  whom  the,  physical  or  nervous  tax 
would  be  too  great,  nor  should  it  be  employed  in  a  tooth  the  peri- 
dental membrane  of  which  is  so  greatly  impaired  as  to  revolt 
seriously  against  the  impact  of  the  mallet.  In  short,  the  best 
judgment  and  the  closest  discrimination  should  be  exercised  to  the 
end  that  this  king  of  all  filling-materials  be  not  crucified  by  the 
enthusiastic  unwisdom  of  its  chief  advocates. 

Combinations  of   Gold  with  Other  Materials. 

Gold  and  Platinum. — This  material  makes  a  harder  filling 
and  one  capable  of  greater  wear  than  gold  alone.  It  is  also — as 
has  been  indicated — ^possible  to  produce  with  it  fillings  of  varying 
degrees  of  shade  which  may  be  made  to  harmonize  agreeably  with 
the  different  types  of  patients  which  come  under  our  hands. 
These  degrees  of  shade  are  regulated  by  the  percentage  of  gold 
and  platinum  in  the  given  product.  One  preparation  contains  more 
gold  than  platinum,  another  about  equal  parts,  while  a  third  has  a 


FILLING-MATERIALS.  155 

preponderance  of  platinum,  and  the  color  is  thereby  affected  so  as 
to  range  from  a  decidedly  yellowish  to  a  decidedly  grayish  tinge. 
This  variation  of  the  material  may  be  used  to  striking  advantage 
in  harmonizing  the  filling  with  the  features  of  the  patient.  The 
soft  gray  platinum  shade  falls  in  beautifully  with  the  general 
effect  in  the  mouth  of  a  decided  brunette,  while  the  varying  gra- 
dations from  that  to  a  light  blonde  may  be  followed  with  artistic 
results  by  a  careful  selection  of  the  corresponding  shades  of  ma- 
terial. 

The  combination  of  gold  and  platinum  should  be  employed  to  a 
greater  extent  by  the  profession  than  it  is  to-day,  for,  while  its 
manipulation  is  somewhat  more  exacting  than  that  of  gold,  its  in- 
telligent use  will  lead  to  artistic  results  not  attainable  with  gold 
alone,  and  its  superior  density  adds  greater  permanence  to  the  sur- 
faces of  all  fillings  which  are  in  any  way  subject  to  attrition.  Its 
manipulation  will  be  considered  later. 

Gold  and  Tin. — This  combination  of  materials  possesses  quali- 
ties which  should  commend  it  to  the  favorable  attention  of  the  pro- 
fession. If  its  limitations  are  understood  and  the  cases  carefully 
selected  for  its  use,  it  will  prove  a  source  of  great  satisfaction  both 
to  patient  and  practitioner;  and  it  is  therefore  worthy  of  sufficient 
merit  to  induce  every  operator  to  study  its  characteristics  and 
master  the  details  of  its  manipulation.  The  claim  has  been  made 
that  it  possesses  no  virtues  which  may  not  be  found  in  non-cohesive 
gold,  but  in  two  important  particulars  this  wovild  seem  to  be  an 
error.  The  tin  foil  imparts  to  the  mass  a  quality  which  non-cohe- 
sive gold  does  not  possess,  viz,  a  lead-like  consistence  which  makes 
the  product  tougher  and  more  readily  adapted  to  walls  of  cavities. 
A  plugger-point  will  not  penetrate  gold  and  tin  so  easily  as  it  will 
a  similar  mass  of  non-cohesive  gold;  and  another  important  item 
is  the  fact  that  the  filling  will  build  up  more  rapidly  under  the 
plugger  than  will  gold  with  equal  manipulation.  A  filling  of  gold 
and  tin  may  therefore  be  inserted  in  less  time  than  a  similarly 
condensed  filling  of  gold.  But  probably  the  most  important  dif- 
ference between  this  comh)ination  and  non-cohesive  gold  lies  in 
the  fact  that  in  most  instances,  after  a  filling  of  gold  and  tin  has 


15  C  PRINCIPLES    AND    PJRACTICE    OF    FILLING    TEETH. 

been  inserted  for  a  time,  the  material  undergoes  a  change  which 
renders  it  much  harder  than  it  originally  was,  or  than  non-cohe- 
sive gold  can  possibly  be  made.  It  becomes  crystalline  in  char- 
acter, so  that  the  filling  is  an  integral  mass,  with  little  distinction 
between  the  gold  and  the  tin.  When  it  is  first  inserted,  it  is  easily 
picked  apart;  but  after  several  years'  service  in  the  mouth  it  be- 
•comes  almost  vitreous  in  nature,  so  that  an  excavator  when  drawn 
across  it  will  respond  with  a  metallic  vibration.  It  has  lost  its 
dead  softness  and  taken  on  a  crystalline  character  which  greatly 
increases  its  resisting  properties  and  adds  to  its  serviceability. 

Its  limitations  consist  in  the  fact  that  it  will  discolor  in  the 
mouth,  so  that  it  cannot  be  used  in  any  position  where  it  may  be 
seen,  and  also  that  it  can  never  be  built  into  contours  or  used  in 
cavities  of  sufficiently  large  area  to  bring  any  considerable  attrition 
of  mastication  upon  it.  The  indications  for  its  use  relate  princi- 
pally to  occlusal  cavities  in  molars  and  bicuspids  for  children,  and 
along  the  gingival  third  of  deep  occluso-proximal  cavities  in  molars 
and  bicuspids  where  the  main  body  of  the  filling  is  to  be  of  gold. 
It  is  especially  useful  in  this  latter  case  on  account  of  materially 
shortening  the  operation  and  avoiding  any  possibility  of  discomfort 
from  thermal  changes,  owing  to  the  reduced  conductive  properties 
of  the  tin  in  the  combination.  The  rapidity  with  which  it  may  be 
inserted  renders  it  a  very  desirable  material  in  the  mouths  of 
children,  where  the  avoidance  of  the  rubber  dam  is  an  important 
consideration. 

Gold  and  tin  cannot  be  expected  to  do  the  same  length  of  ser- 
vice as  gold  in  any  position  where  it  is  subjected  to  the  constant 
attrition  of  mastication,  and  yet  many  of  these  occlusal  fillings 
which  have  been  under  observation  for  ten  or  twelve  years  give 
€very  prospect  of  long-continued  usefulness, — their  length  of  ser- 
vice in  most  cases  being  out  of  all  proportion  to  the  limited  time 
necessary  for  their  insertion. 

Gold  and  Iridium. — This  combination  has  gained  little  atten- 
tion from  the  profession,  nor  has  it  much  to  recommend  it  as  a 
filling-material.  By  its  use  a  harder  surface  may  be  given  a 
filling  than  is  possible  Avith  gold,  but  on  being  finished  it  presents  a 


FILLING-MATERIALS. 


157 


brassy  appearance  not  pleasing  to  the  eye,  and  it  is  therefore  ap- 
plicable only  to  posterior  teeth.  Even  in  these  cases  there  is 
seldom  an  instance  where  gold  and  platinum  will  not  do  equal 
serA-ice  and  present  a  more  artistic  effect. 

Amalgam. 

This  material  has  been  at  once  the  refuge  and  despair  of  the 
dental  profession.  It  has  probably  saved  teeth  that  never  would 
have  been  saved  without  it,  but,  even  in  the  hands  of  its  most 
enthusiastic  advocates,  it  has  so  often  proved  a  disappointment  that 
observant  men  can  no  longer  remain  blind  to  its  limitations.  The 
investigations  of  Fletcher,  Flagg,  Bogue,  Black,  Wedelstaedt,  and 
others  have  thrown  much  light  on  its  characteristics ;  but  even  with 
the  most  that  has  been  learned  of  it,  and  the  best  that  has  been  said 
of  it,  the  fact  remains  that  much  of  the  amalgam  now  offered  the 
profession  is  ill  adapted  to  the  permanent  saving  of  teeth.  ISTor 
are  we  likely  soon  to  have  in  general  use  amalgams  which  may  be 
uniformly  depended  upon, — not  because  a  reasonably  reliable 
grade  of  amalgam  is  impossible  of  manufacture,  but  because  the 
conditions  necessary  to  produce  it  are  so  exacting  and  the  process 
so  intricate  that  few  men  will  be  found  sufficiently  painstaking  to 
invariably  furnish  it. 

The  chief  faults  with  amalgam,  as  presented  to  us  in  the  past. 
have  exhibited  themselves  in  a  tendency  to  compress  under  the 
impact  of  mastication,  so  as  to  be  drawn  away  from  the  cavity- 
walls,  but  more  particularly  in  a  tendency  to  so  change  form, 
even  after  crystallization  has  taken  place  and  where  no  undue 
pressure  is  exerted,  as  to  produce  a  serious  leak  between  the  filling 
and  the  wall  of  the  cavity.  This  is  frequently  exhibited  in  a  de- 
cided crack  along  the  cavity-margins,  easily  visible  to  the  naked 
eye,  and  capable  of  allowing  the  ingress  of  deleterious  agents  cal- 
culated to  bring  about  recurrence  of  decay  around  the  filling. 
These  cracks  do  not  need  to  be  large  enough  to  be  seen  in  order  to 
invite  mischief,  and  very  many  teeth  have  been  lost  in  the  past  as 
the  result  of  this  one  characteristic  of  amalgam.  The  color  of 
amalgam  is  also  against  it,  but  particularly  the  fact  that  much  of 


158  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

the  amalgam  used  bj  the  profession  has  so  changed  color  after 
its  insertion  in  the  mouth  as  to  render  it  most  unsightly.  Neither 
has  the  blackening  process  always  been  confined  to  the  material 
itself, — the  teeth,  in  many  instances,  being  so  badly  stained  by  it 
as  to  remain  discolored  for  life. 

These  various  faults  of  amalgam  have  claimed  the  attention  of 
the  profession  for  years,  but  no  one  would  seem  to  have  overcome 
them  in  any  encouraging  degree  till  the  investigations  of  Dr. 
Black.  After  the  most  painstaking  study  of  the  physical  character 
of  the  various  alloys,  he  was  finally  enabled  to  produce  one  which 
would  neither  shrink  nor  expand,  and  which  would  sustain  sulEfi- 
cient  stress  to  make  it  reasonably  serviceable  in  the  mouth.  But 
the  conditions  surrounding  the  manufacture  and  manipulation  of 
such  an  alloy  are  so  intricate  and  so  exacting,  and  the  ingredients 
so  sensitive  to  the  slightest  variation  in  temperature  or  in  treat- 
ment, that  to  produce  a  uniform  product  from  one  time  to  another 
would  seem  to  be  well-nigh  beyond  the  possibility  of  human  attain- 
ment. Manufacturers  find  that  an  ingot  melted  from  a  given 
formula  may  give  a  certain  result,  while  another  ingot  from  the 
same  formula,  and  apparently  treated  in  the  same  way,  will  show 
a  variation  in  the  result.  The  closest  attention  to  the  minutiae  is, 
therefore,  necessary  all  along  the  line,  from  the  refining  of  the 
original  metals  down  to  the  filing  and  annealing  of  the  finished 
product.  Even  then  no  one  batch  of  alloy  should  ever  be  sent 
out  short  of  a  final  test  of  the  amalgam  made  from  it  by  the  most 
delicate  machinery;  and,  in  passing,  it  may  be  stated  that  when 
these  tests  are  made  they  frequently  prove  a  source  of  discourage- 
ment to  the  conscientious  manufacturer.  Discrepancies  arise  at 
every  hand  where,  apparently,  the  greatest  care  had  been  taken 
with  the  preparation,  and  the  more  this  amalgam  question  is 
studied,  the  more  it  would  seem  to  be  hedged  about  by  limitations 
so  great  as  to  be  disheartening  in  view  of  the  immense  amount  of 
the  material  being  used  at  the  present  day.  It  would  probably 
be  better  for  the  profession  and  the  public  if  much  of  the  energy 
which  is  now  being  expended  on  amalgam  were  diverted  to  other 
materials  which  are  capable  of  more  definite  and  uniform  results. 


FILLING-MATERIALS.  159 

Aud  yet  amalgam  under  existing  conditions  cannot  well  be  ex- 
cluded from  our  present  list  of  filling-materials.  It  has  been  too 
useful  for  certain  purposes,  even  with  its  limitations,  to  be  entirely 
discarded.  Its  chief  utility  relates  to  the  building  up  of  teeth  so 
badly  broken  down  or  so  remotely  situated  in  the  mouth  as  to  ren- 
der the  use  of  gold  too  exacting,  and  also  to  the  saving  of  teeth 
whose  peridental  membranes  are  so  impaired  as  to  preclude  the  use 
of  the  mallet.  Employed  with  discriminating  care,  amalgam  may, 
under  these  conditions,  serve  a  useful  purpose;  but  it  can  never 
hope  to  attain  to  the  same  degree  of  excellence  as  a  saver  of  teeth 
that  has  long  since  been  established  by  gold. 

Tin. 

The  statement  has  often  been  made  that  this  material  does  not 
claim  from  the  profession  the  attention  which  its  virtues  merit, 
and  this  is  probably  true,  though  it  would  seem  that  the  combina- 
tion of  gold  and  tin  possesses  all  of  the  advantages  of  tin  alone, 
together  with  the  added  virtue  of  being  better  able  to  resist  wear 
on  account  of  its  greater  hardness. 

Tin  may  be  used  in  one  of  two  forms, — that  of  foil,  or  in  the 
form  of  shavings  cut  from  block  tin.  The  former  is  perfectly 
non-cohesive,  while  the  latter,  if  freshly  cut,  is  said  to  possess  cohe- 
sive properties,  though  tin  cannot  be  built  into  contours  with  any 
assurance  of  permanence  on  account  of  its  softness.  The  indica- 
tions for  the  use  of  tin  are  practically  the  same  as  those  suggested 
for  gold  and  tin, — it  being  especially  useful  in  any  position  where 
it  is  surrounded  by  four  walls  and  is  not  subjected  to  wear.  It  is 
readily  adapted  to  the  cavity,  will  retain  its  form  perfectly,  except 
under  pressure,  and  it  is  a  poor  conductor.  This  suggests  that  tin 
may  serviceably  be  employed  in  simple  cavities  on  all  posterior 
teeth,  such  as  buccal  or  lingual  cavities  of  limited  area,  or  in  proxi- 
mal cavities  which  do  not  involve  the  occlusal  surface. 

Cements. 
There  are  three  main  varieties  of  cement, — the  oxychloride  of 
zinc,  the  oxyphosphate  of  zinc,  and  the  oxyphosphate  of  copper. 
The  oxychloride  of  zinc  is  indicated  in  pulpless  teeth,  for  filling  the 


160  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

pulp-chamber  after  the  canals  have  been  previouslj  filled  with 
gutta-percha,  and  also  to  form  a  lining  to  the  cavity  under  the  fill- 
ing proper.  It  is  seldom  indicated  in  teeth  with  living  pulps,  par- 
ticularly if  there  is  a  near  approach  to  the  pulp  or  if  there  is  much 
hypersensitiveness,  on  account  of  its  strong  irritating  properties. 
J^either  can  it  be  relied  on  for  reasonable  service  in  any  position 
where  it  is  subjected  to  the  fluids  of  the  mouth,  from  the  fact  that 
it  is  so  readily  dissolved, — ^this  being  especially  true  of  proximal 
cavities  at  the  gingival  margin. 

The  oxyphosphate  of  zinc  is  an  excellent  agent  as  an  inter- 
mediate under  metal  fillings  in  cases  where  there  is  a  near  approach 
to  the  pulp, — it  being  less  of  an  irritant  than  the  oxychloride, — 
and  also  for  a  temporary  filling-material  in  the  management  of 
teeth  which  for  any  reason  may  not  be  in  a  condition  for  a  perma- 
nent operation.  Its  chief  limitation  consists  in  a  tendency  to  dis- 
solve under  the  fluids  of  the  mouth,  though  it  is  not  so  subject  to 
this  fault  as  is  the  oxychloride,  and  there  is  a  considerable  variation 
in  its  behavior  in  different  mouths.  In  some  instances  it  seems  to 
wear  well  for  years,  particularly  if  the  material  used  is  of  superior 
quality  and  it  receives  proper  manipulation,  but  at  best  it  may  be 
accounted  only  a  temporary  expedient,  and  should  not  be  relied  on 
for  permanent  service, 

The  oxyphosphate  of  copper,  introduced  by  Dr.  Ames,  of  Chi- 
cago, is  also  somewhat  soluble  in  the  mouth,  particularly  in  vulner- 
able positions;  and  the  fact  that  it  is  intensely  black  in  color  limits 
its  use  to  positions  not  exposed  to  view.  It  is  especially  indicated 
in  remote  cavities  on  the  necks  of  teeth  occasioned  by  a  recession 
of  the  gum,  where  the  cavity  is  so  ill  defined  as  to  make  the  use  of 
gutta-percha  or  amalgam  difiacult.  It  may  be  made  to  adhere  to 
the  surface  of  a  cavity  very  tenaciously,  so  that  little  undercutting 
is  necessary,  and  it  will  prove  an  excellent  expedient  in  that  par- 
ticular class  of  cases  for  which  no  other  kind  of  filling  seems  suited.. 

Gutta-Percha. 

This  is  a  material  which  deserves  more  attention  from  the  pro- 
fession than  it  has  received.     In  the  particular  field  for  which  it  is 


FILLI^X.-MATERIAL8.  161 

best  suited  it  has  no  equal,  and  its  uses  are  varied  and  unique  in  the 
saving  of  teeth.  Its  chief  limitation  lies  in  the  fact  that  it  is  not 
sufficiently  hard  to  withstand  attrition,  but  placed  in  positions  se- 
cure from  wear  it  gives  most  excellent  results.  It  is  not  dissolved 
bv  the  fluids  of  the  mouth,  and  it  is  one  of  the  best  of  non-conduc- 
tors. As  a  temporary  sealing  agent  in  the  treatment  of  teeth  it  is, 
without  question,  the  best  material  we  possess.  It  is  especially  in- 
dicated for  the  filling  of  pulp-canals,  being  non-irritant,  impervious 
to  moisture,  and  readily  molded  to  fit  any  inequality  in  the  canal. 
It  is  also  very  valuable  as  a  temporary  filling-material  in  connec- 
tion with  oxyphosphate  of  zinc  for  proximal  cavities,  the  gutta- 
percha being  used  in  the  gingival  third  of  the  cavity  and  the  filling 
completed  with  cement.  Gutta-percha  will  not  dissolve  out  under 
these  conditions,  as  will  any  of  the  cements;  nor  will  the  latter 
wear  away  so  rapidly  under  attrition  as  will  gutta-percha,  so  that 
by  combining  the  two  materials  in  this  manner  in  the  same  cavity 
the  operator  gains  the  advantage  of  more  adequate  protection  to 
the  gingival  margin  and  a  better  wearing  service  on  the  occlusal 

portion  of  the  filling. 

Inlays. 

The  discussion  of  filling-materials  at  the  present  time  would 
hardly  be  complete  without  a  consideration  of  inlays.  The  desira- 
bility of  controlling  caries  in  the  anterior  part  of  the  mouth,  with- 
out the  necessity  for  an  objectionable  display  of  gold,  would  seem 
to  be  apparent,  as  also  would  the  possibility  of  saving  badly  de- 
cayed teeth  in  any  location  where  the  insertion  of  gold  foil  is  con- 
traindicated  on  account  of  too  great  tax  on  the  patient,  or  too  much 
infliction  on  an  impaired  peridental  membrane  by  the  mallet. 
Crown-work,  as  the  result  of  the  considerations  just  indicated,  has 
often  >>een  resorted  to  by  operators  in  oases  of  extended  decay  at  a 
period  earlier  than  would  make  crowning  justifiable  if  some  more 
feasible  means  could  be  employed  to  tide  the  tooth  over  a  number 
of  years.  It  is  in  cases  of  this  kind  that  inlay  work  finds  its  most 
legitimate  field.  This  would  seem  to  be  an  intimation  that  inlays 
are  to  be  considered  more  or  less  temporary  in  their  nature,  and 
from  our  past  experience  with  them,  and  our  present  resources  in 

11 


102  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

their  manufacture  and  methods  of  setting,  this  fact  must  seem  un- 
deniable.: 

It  will  scarcely  do  to  point  to  a  few  isolated  cases  where  inlays 
have  done  an  excellent  and,  to  all  intents,  a  permanent  service,  and 
thereby  claim  that  inlays  are  in  the  main  trustworthy  for  extended 
use.  There  are  principles  involved  in  the  process  of  their  manu- 
facture, and  in  the  means  employed  to  secure  them  in  the  cavity, 
which  cannot  by  any  sort  of  skill  on  the  part  of  the  operator,  or 
any  sort  of  reasoning  on  the  part  of  their  advocates,  be  overcome  so 
as  not  to  interfere  with  perfection  of  results.  A  metal  matrix  for 
receiving  the  material  of  the  inlay,  whether  it  be  of  gold,  or  glass, 
or  porcelain,  cannot  by  present  methods  be  so  adapted  to  the  walls 
of  the  cavity  as  to  prevent  the  penetration  of  moisture ;  neither  can 
it  be  fashioned  to  remain  firm  in  the  cavity  vidthout  something  to 
hold  it.  To  overcome  these  mechanical  discrepancies,  some  ma- 
terial must  be  used  to  seal  the  interstice  between  the  inlay  and  the 
cavity,  and  to  retain  the  inlay  in  position  by  reason  of  its  ad- 
hesive properties.  Up  to  the  present  time  no  suitable  material 
has  been  discovered  which  is  not  open  to  the  objection  of  being 
more  or  less  soluble  in  the  fluids  of  the  mouth.  It  is  true  that  with 
an  expert  and  careful  operator,  and  a  material  manufactured  and 
used  in  the  light  of  the  most  recent  investigations,  these  imper- 
fections may  in  some  degree  be  overcome,  but  with  our  present 
knowledge  they  cannot  hope  to  be  entirely  obliterated. 

If  the  too  enthusiastic  advocates  of  inlays  would  recognize  •this' 
fact,  and  would  more  carefully  discriminate  in  their  selection  of 
cases,  the  future  of  inlay  work  would  be  more  secure  than  it  seems 
to  be  at  "present.  There  is  a  useful  purpose  for  it  to  perform  in  the 
profession,  but  from  existing  indications  it  would  appear  that  it  is 
doomed,  as  many  another  worthy  object,  to  be  made  the  victim  of 
its  overzealous  friends. 

The  cases  most  suited  to  the  reception  of  inlays  are  in  cavities 
on  exposed  surfaces  of  the  anterior  teeth,  and  in  large  cavities  in 
bicuspids  and  molars  where  filling  operations  would  prove  too  ex- 
hausting. The  former  should  be  of  porcelain,  for  esthetic  reasons, 
while  the  latter  should  be  of  gold.     Gold  inlays  are  more  easily 


FILLING-MATERIALS.  163 

made  than  porcelain,  and  in  localities  subject  to  the  stress  of  mas- 
tication are  much  less  liable  to  fracture.  They  should  therefore 
invariably  be  used  in  any  position  not  exposed  to  view,  and  it  is 
in  this  particular  class  of  inlay  work  that  the  most  satisfactory  and 
permanent  results  are  to  be  obtained. 

It  should  be  a  cardinal  principle  with  every  operator  who  uses 
inlays  to  so  inform  his  patients  on  the  subject  that  they  shall  return 
at  stated  intervals  for  examination  of  the  work,  with  the  expectancy 
of  an  occasional  resetting,  as  the  result  of  disintegration  of  the 
cement,  except  in  the  case  of  gold  inlays  where  the  cavity -mar- 
gins have  been  freely  beveled  and  the  gold  carried  over  them  so 
as  to  protect  the  cement  and  prevent  its  solution.  To  do  less  than 
this  with  our  present  light  on  the  subject  is  to  be  seriously  derelict 
in  duty. 

A  certain  class  of  patients  will  cheerfully  submit  to  the  periodi- 
cal replacement  of  porcelain  inlays  in  preference  to  having  an  exhi- 
bition of  gold  in  the  mouth,  and  yet  it  may  be  well  just  at  this 
point  to  look  somewhat  carefully  into  the  probable  results  of  doing 
too  much  of  this  temporary  class  of  work.  While  some  individuals 
possessed  of  a  high  sense  of  the  esthetic  and  with  unlimited 
patience  will  follow  up  this  work  with  the  faithfulness  its  nature 
demands,  the  great  majority  will  after  a  time  become  wearied  and 
fall  by  the  wayside.  This  is  not  conducive  to  confidence  in  the 
profession  as  to  their  ability  to  save  teeth,  and  the  general  impres- 
sion on  the  people  will  be  unfortunate.  The  enviable  reputation 
which  dentistry  possesses  to-day  as  a  calling  capable  of  rendering 
unique  and  lasting  service  to  the  human  race  was  not  obtained  by 
the  performance  of  ephemeral  operations.  It  is  the  result  of  hard, 
liainstaking  effort  on  the  part  of  our  illustrious  predecessors,  whose 
supreme  effort  was  aimed  in  the  direction  of  producing  such  work 
as  would  prove  of  the  greatest  possible  permanence  and  utility  to 
their  patients.  It  is  safe  to  conclude  that  it  could  never  have  been 
accomplished  by  the  general  use  of  inlay  work. 


164  PRINCIPLES    AJSiD    PRACTICE    OF    FILLING    TEETH. 

CHAPTEK    VI  I. 

GOLD. 

Cohesive  and  Non-Cohesive  Gold. 

All  gold  for  filling  teeth  should  be  as  pure  as  it  can  be  made. 
The  distinction  between  cohesive-  and  non-cohesive  gold  does  not 
so  much  relate  to  its  purity  as  to  the  condition  of  its  surface.  If 
two  layers  of  gold  foil  which  is  perfectly  pure  and  perfectly  clean 
upon  its  surface  be  brought  into  intimate  contact  at  ordinary 
temperatures,  they  will  cohere.  In  other  words,  they  will  weld 
cold.  Two  pieces  of  gold  in  this  condition  cannot  be  rubbed  to- 
gether without  sticking.  This  is  an  inherent  quality  of  gold  when 
pure  and  clean,  and  it  is  gold  in  this  state  which  is  termed  cohesive 
gold. 

If  pure  gold  foil  be  exposed  to  the  atmosphere  for  any  length  of 
time,  or  is  brought  in  contact  with  certain  gases,  it  gathers  upon  its 
surface  an  imperceptible  film,  which,  while  not  affecting  the 
purity  of  the  substance  itself,  interferes  with  its  cohesion.  Two 
layers  of  foil  in  this  condition  may  be  rubbed  together  without 
adhering.     This  is  called  non-cohesive  gold. 

In  accordance  with  this,  it  might  naturally  be  assumed  that, 
given  a  piece  of  pure  and  clean  gold  foil,  it  could  be  made  cohe- 
sive or  non-cohesive  at  will,  and  this  is  in  strict  agreement  with 
fact.  A  pellet  of  cohesive  gold  may  be  made  non-cohesive  by  ex- 
posing it  to  the  influence  of  ammonia  gas,  and  this  pellet,  thus 
rendered  non-cohesive,  may  in  turn  be  made  cohesive  by  driving 
off  the  gas  with  heat.  It  is  on  this  hypothesis  that  we  anneal 
our  gold  for  filling  teeth.  But  there  are  some  gases  which,  if  al- 
lowed to  come  in  contact  with  the  surface  of  gold  foil,  apparently 
cannot  be  driven  off  by  heat,  and  thus  render  the  gold  permanently 
non-cohesive.  Exposure  to  the  atmosphere  under  certain  condi- 
tions for  an  extended  period  seems  to  have  the  same  effect,  so  that 
operators  who  wish  their  gold  to  work  uniformly  fresh  and  cohe- 
sive should  keep  it  protected  from  the  atmosphere. 


GOLD.  165 

The  difference  in  behavior  of  cohesive  and  non-cohesive  gold 
under  the  plugger  is  readily  suggested  by  the  characteristics  of  the 
two  materials.  From  the  fact  that  with  non-cohesive  gold  one 
pellet  may  be  forced  across  another  without  adhering  to  it  we  are 
able  conveniently  to  carry  such  gold  into  corners  of  cavities  diffi- 
cult of  access  and  secure  ready  adaptation  to  walls,  but  the  absence 
of  cohesion  between  the  layers  of  foil  limits  us  in  any  attempt  to 
build  it  into  contours.  With  cohesive  gold  we  have  the  advantage 
of  giving  any  desired  form  to  the  filling  and  obtaining  increased 
strength  to  the  mass,  with  the  limitation  of  greater  difficulty  in 
securing  adaptation  to  points  not  easy  of  access.  This  does  not 
imply  that  adequate  adaptation  cannot  be  gained  with  cohesive 
gold.  Cohesive  gold  may  be  adapted  to  the  wall  of  a  cavity  with 
as  great  a  degree  of  perfection  as  can  non-cohesive,  but  the  method 
of  manipulation  is  more  exacting  and  less  rapid. 

From  the  fact  that  a  pellet  of  cohesive  gold  will  immediately 
stick  to  gold  which  has  already  been  placed  in  the  cavity,  care  must 
be  exercised  in  adding  each  fresh  pellet  to  locate  it  in  precisely 
the  position  where  it  is  intended  to  condense  it.  If  it  is  allowed  to 
come  in  contact  with  any  part  of  the  surface  remote  from  the  point 
indicated,  it  cannot  be  forced  across  the  surface  to  the  proper  posi- 
tion on  account  of  its  cohesion.  With  non-cohesive  gold  there  is 
more  latitude  in  this  particular,  but,  properly  placed  and  thor- 
oughly condensed,  cohesive  gold  may  be  made  to  seal  a  cavity  per- 
fectly. 

Annealing  Gold. 

Much  of  the  difficulty  experienced  by  operators  in  the  insertion 
of  gold  is  due  to  faulty  methods  of  annealing;  and,  even  among 
operators  who  are  sufficiently  skilled  to  obtain  good  results  by  the 
ordinary  methods,  there  is  much  to  be  gained  by  adopting  some  of 
the  more  recent  advances  in  this  important  particular.  The  great 
majority  of  operators  are  in  the  habit  of  annealing  their  gold  by 
passing  it  through  the  flame  of  a  spirit  lamp  or  a  Bunsen  burner, — 
a  method  which  has  serious  objections.  In  either  instance  we  are 
never  certain  of  always  having  a  pure  flame,  and  if  we  do  not  have 
a  pure  flame  we  jeopardize  the  working  quality  of  the  gold.     An 


166  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

alcohol  flame  is  seldom  imif orm  in  its  character,  from  the  fact  that 
it  is  so  appreciably  affected  by  atmospheric  changes.  An  undue 
humidity  in  the  operating  room  will  result  in  a  vitiated  flame, 
which  shows  itself  in  a  yellowish  tinge.  The  presence  of  moisture 
in  the  air  always  affects  this  flame,  owing  to  the  great  aflinity  which 
alcohol  has  for  water. 

The  gas  flame  from  a  Bunsen  burner  is  more  reliable  than  the 
alcohol  flame,  but  it  is  not  without  its  limitations.  The  operator  is 
always  dependent  on  the  gas  company  to  furnish  him  a  pure  qual- 
ity of  gas,  and  he  must  watch  the  burner  to  keep  it  in  perfect  work- 
ing order  if  he  expects  a  uniform  flame.  Even  at  the  best,  it  is 
doubtful  if  gold  coming  in  contact  with  any  flame  is  not  more  or 
less  contaminated  thereby. 

Then  the  manner  of  annealing  followed  by  many  operators  is 
calculated  to  give  unequal  results,  even  with  a  pure  flame.  If  a 
pellet  of  gold  be  picked  up  by  the  pliers  and  carried  through  the 
flame  and  then  to  the  filling,  as  is  so  frequently  done,  nearly  one- 
half  of  the  pellet  is  imperfectly  annealed.  The  portion  of  gold 
grasped  by  the  pliers  is  not  annealed  at  all,  and  for  some  distance 
from  the  plier-points  the  gold  is  kept  sufliciently  cooled  by  the 
points  to  prevent  perfect  annealing.  This  accounts  for  much  of 
the  pitting  on  the  surfaces  of  some  gold  fillings.  A  certain  portion 
of  every  pellet  is  left  non-cohesive,  and  when  wear  is  brought  upon 
the  filling  these  little  particles  which  were  grasped  by  the  plier- 
points  flake  off,  leaving  an  imperfect  surface.  The  operator  does 
not  notice  this  defect  while  building  up  the  filling  because  of  the 
fact  that  the  end  of  the  pellet  most  remote  from  the  pliers  is  well 
annealed,  and  this,  coming  in  contact  with  the  gold  in  the  cavity, 
adheres  perfectly,  and  the  whole  pellet  seems  to  mallet  down  to 
place  in  good  condition.  It  is  only  when  subsequent  attrition  on 
the  filling  discloses  the  flaked  surface  that  the  operator  realizes 
there  is  something  wrong  with  the  density  of  his  gold;  and  even 
then  he  is  quite  likely  to  attribute  it  to  some  inherent  defect  in  the 
gold  rather  than  to  faulty  methods  on  his  part.  This  plan  of 
annealing  also  occasionally  leads  to  another  detrimental  effect. 
The  operator,  in  observing  the  pellet  in  the  flame,  notes  that  it  is 


GOLD.  167 

dark  in  color  for  more  than  half  its  length  from  the  plier-points, 
and  attempts  to  get  a  uniform  heating  by  holding  it  longer  in  the 
ilame.  This  results  in  the  overheating  of  the  pellet  at  the  end 
most  remote  from  the  pliers,  and  the  fusing  together  of  the  layers 
of  foil  at  that  point  so  as  to  present  a  harsh,  unyielding  mass,  with 
which  it  is  impossible  to  do  uniform  work.  If  an  operator  must 
employ  the  flame  for  annealing  he  would  better  use  the  smallest 
pliers  obtainable,  and  grasp  the  minute  corner  of  one  end  of  the 
pellet  and  pass  it  carefully  through  the  flame,  or  near  the  flame,  till 
the  other  end  reddens.  Then,  dropping  the  pellet  in  the  gold 
drawer,  he  should  pick  it  up  again  at  the  annealed  end  and  gently 
heat  the  other  one.  In  this  way  both  ends  are  annealed ;  but  even 
then  there  is  a  lack  of  uniformity  in  such  a  method,  and  it  also  re- 
quires unnecessary  time  and  undue  manipulation  of  the  pellet 
before  it  reaches  the  cavity.  A  pellet  should  be  handled  as  little 
as  need  be  from  the  time  it  leaves  the  gold-beater  till  it  is  placed  in 
position  in  the  tooth. 

Another  method  employed  by  some  operators  to  obviate  the 
difficulties  just  indicated  is  to  roll  their  foil  into  a  rope  of  suitable 
size,  and  then  anneal  the  entire  rope,  cutting  it  into  pellets  subse- 
quently. An  objection  to  this  is  found  in  the  fact  that  with  a  rope 
of  annealed  gold  the  impact  of  the  scissors  in  cutting  the  pellets 
compresses  the  rope  so  that  there  is  a  line  of  condensed  gold  across 
each  end  of  each  pellet  before  it  is  placed  in  the  cavity.  This  may 
appear  a  trivial  consideration,  and  yet  it  is  attention  to  the  minutia^ 
which  goes  to  make  up  the  most  perfect  result  in  the  insertion  of 
gold.  A  pellet  condensed  at  either  end  in  this  way  is  not  so 
obedient  to  the  plugger,  nor  can  it  be  so  accurately  manipulated  in 
the  performance  of  delicate  work  as  can  a  uniform  pellet. 

The  plan  of  some  operators  whereby  the  plugger-point  is  used 
to  pick  the  gold  from  the  drawer  and  carry  it  to  the  flame  and  then 
to  the  cavity,  is  objectionable  in  several  particulars.  Unless  the 
point  is  heated  sufficiently  to  ruin  its  quality  as  a  plugger,  the  gold 
is  never  perfectly  annealed  in  the  region  of  the  point.  If  it  is 
annealed  at  all  adequately,  the  point  is  made  so  hot  as  to  be  pain- 
ful to  the  patient  on  application  to  the  tooth,  and  the  products  of 


168  PKINCIPLES    AND    PEACTICE    OF    FILLING    TEETH. 

repeated  oxidation  at  the  end  of  the  point  are  continually  being- 
incorporated  into  the  structure  of  the  filling,  which,  at  best,  cannot 
result  to  its  benefit.  There  is  also  a  lack  of  uniformity  in  the 
degree  of  annealing  throughout  the  pellet,  the  ends  being  invari- 
ably heated  higher  than  the  part  touched  by  the  plugger-point. 
The  same  condition  exists,  though  in  a  modified  degree,  when  a 
smaller  instrument  is  used  for  picking  up  the  gold  in  lieu  of  a 
plugger,  as  practiced  by  some  operators.  Another  minor  objec- 
tion relates  to  the  fact  that  when  a  pellet  is  annealed  in  this  way  it 
has  a  tendency  to  slightly  change  its  form  under  the  flame,  so  as  to 
drop  from  the  j)lugger  or  annealing  instrument  and  fall  into  the 
flame. 

In  view  of  these  considerations,  it  would  seem  desirable  for  the 
profession  to  adopt  a  different  method  of  annealing  gold  to  obtain 
the  best  results.  The  problem  to  be  solved  is  simply  to  heat  the 
gold  sufficiently  to  effectively  drive  off  all  gases  from  its  surface 
without  the  possibility  of  concurrent  contamination,  and  with  abso- 
lute uniformity  of  annealing  throughout  the  mass.  Various 
methods  have  been  devised  for  this  purpose,  the  one  most  em- 
ployed in  the  past  being  to  place  the  gold  on  a  mica  or  metal 
tray  over  the  spirit  lamp,  and  allow  the  heat  thus  generated  to 
gradually  accomplish  the  purpose;  but  the  most  perfect  method 
yet  suggested  is  through  the  medium  of  the  electric  gold  annealer 
devised  by  Dr.  L.  E.  Custer,  of  Dayton,  Ohio.  With  this  appliance 
complete  uniformity  of  result  is  obtained  in  the  most  convenient 
and  ready  manner,  and  with  no  liability  of  contamination.  Even 
to  operators  who  have  been  accomplishing  apparently  satis- 
factory results  by  other  means,  this  appliance  will  soon  reveal  a 
working  quality  to  the  gold  which  seems  impossible  of  attainment 
in  any  other  way,  and  it  is  confidently  believed  that  its  general 
adoption  by  the  profession  would  disarm  much  of  the  criticism 
which  is  occasionally  waged  against  the  manufacturers  of  gold  on 
the  plea  of  lack  of  uniformity  in  preparation.  The  only  procedure 
necessary  is  to  place  the  pellets  in  convenient  arrangement  on  the 
annealer  and  turn  on  the  current,  which  may  be  left  running  to  the 
end  of  the  operation.     IsTo  matter  how  long  the  current  is  on,  there 


GOLD.  169 

is  no  overheating  of  the  gold.     It  simply  anneals  perfectly,  with- 
out ever  fusing  any  of  the  layers  of  the  pellets  together. 

A  most  satisfactory  manner  of  treating  gold  from  the  time  it 
reaches  our  hands  till  it  is  carried  to  the  tooth  is  to  first  subject  it 
to  the  influence  of  ammonia  gas  by  placing  in  a  small  porcelain 
receptacle  a  pledget  of  cotton  saturated  with  aqua  ammonia,  and 
setting  this  in  the  same  drawer  with  the  gold,  leaving  the  box  or 
bottle  containing  the  pellets  open,  so  that  the  gas  may  readily  act 
upon  them.  The  pellets  are  thus  rendered  uniformly  soft,  velvety, 
and  manageable.  They  are  absolutely  non-cohesive.  They  may 
be  shaken  or  rubbed  together  ad  libitum  without  one  pellet,  even 
in  the  slightest  degree,  adhering  to  another.  When  the  filling  is 
to  be  made  they  should  be  transferred  to  the  annealer  and  the  cur- 
rent turned  on,  the  result  of  which  will  furnish  a  series  of  pellets 
each  in  its  behavior  precisely  like  its  fellow.  Gold  treated  in  this 
way  has  a  beautifully  soft  working  quality,  devoid  of  harshness, 
but  capable  of  perfect  cohesion  and  density  under  the  impact  of  tho 
plugger. 

"With  gold  prepared  according  to  these  details,  and  with  the 
characteristics  of  its  manipulation  perfectly  understood,  it  is  nearly 
or  quite  as  easy  of  introduction  into  a  cavity  as  any  of  the  other 
filling-materials,  the  chief  distinction  being  the  greater  length  of 
time  necessary  to  insert  it.  It  must  be  built  up  piece  by  piece, 
while  most  of  the  other  materials  may  be  added  in  masses  of 
greater  bulk. 

For  those  practitioners  who  are  not  convenient  to  the  electric 
current  it  is  suggested  to  employ  gas  for  this  purpose,  by  arrang- 
ing a  series  of  small  jets  on  the  same  principle  as  the  modern  gas 
cooking  burners,  whereby  the  heat  may  be  distributed  as  uniformly 
as  possible  upon  a  given  area,  and  placing  over  this  a  framework 
supporting  a  piece  of  mica  or  other  suitable  material  to  prevent 
contact  of  the  gold  with  the  flame.  On  this  the  gold  may  be  satis- 
factorily annealed,  though  not  so  rapidly  nor  so  perfectly,  so  far 
as  the  regulation  of  heat  is  concerned,  as  by  the  electric  appliance. 
In  case  gas  is  not  available  the  same  arrangement  may  be  made 
with  a  spirit  lamp,  but  this  is  slower  in  its  results,  and  the  heat  is 


170  PRINCIPLES    AiSfD    PRACTICE    OF    FILLING    TEETH. 

less  readily  distributed  with  uniformity  throughout  the  surface  of 
the  annealer. 

It  would  seem  that  either  of  these  methods  was  greatly  to  be  pre- 
ferred to  the  one  so  common  in  vogue  of  passing  the  gold  through 
the  flame,  and  a  careful  consideration  of  this  entire  subject  of  the 
proper  preparation  of  our  gold  for  filling  teeth  is  hereby  strongly 
commended  to  the  profession.  Gold  has  almost  invariably  been 
credited  with  the  advantage  of  having  claimed  a  more  serious 
study  in  its  management  and  a  greater  care  in  its  manipulation 
than  any  other  filling-material  we  possess,  and  yet  in  this  one  par- 
ticular it  would  sometimes  appear  as  if  it  had  been  strangely  mis- 
understood in  its  characteristics  or  ignored  in  its  chief  require- 
ments. 

Different  Forms   of   Gold. 

The  form  in  which  gold  is  used  in  filling  teeth  is  largely  one  of 
individual  preference,  whether  in  ropes,  pellets,  cylinders,  or  strips. 
Possibly  the  best  results  are  obtained  by  a  convenient  arrangement 
of  the  different  forms  in  the  same  cavity,  such,  for  instance,  as 
starting  the  filling  with  a  rope  of  non-cohesive  gold  of  suitable  size 
and  building  the  main  body  of  the  filling  with  pellets  or  cylinders 
annealed,  followed  by  strips  of  heavy  gold  upon  the  surface. 
Some  operators  are  in  the  habit  of  twisting  their  foil  into  ropes,  and 
cutting  these  into  pellets  for  general  use.  Others,  whose  methods 
of  operating  are  highly  individualized,  cut  the  foil  into  strips  and 
roll  these  into  cylinders  of  varying  sizes  for  the  special  case  in 
hand.  One  advantage  of  this  method  is  that  the  layers  of  foil  con- 
stituting the  cylinder  are  arranged  in  a  regular  series,  one  upon 
the  other,  and  are  therefore  capable  of  a  more  even  placement  in 
the  filling  than  when  the  pellets  are  cut  from  a  twisted  rope. 
This  even  arrangement  of  the  layers  of  foil  in  building  a  filling  is 
an  item  of  some  importance  in  its  relation  to  the  strength  of  the 
filling  and  its  uniform  density,  but  the  element  of  time  in  the 
preparation  of  these  cylinders  must  also  be  acknowledged  as  a 
consideration  with  the  busy  practitioner.  The  prepared  pellets  or 
cylinders  of  graded  sizes  and  lengths,  as  they  come  to  us  from  the 
manufacturers,  would  seem  to  furnish  a  most  convenient  form  for 


GOLD.  ITI 

the  bulk  of  our  Avork,  and  these,  supplemented  on  the  surface  in 
cases  calling  for  special  density  with  strips  cut  from  ISTos.  30,  60, 
or  120  rolled  gold,  are  capable  of  producing  a  uniformly  good 
result.  For  the  rapid-acting  mallet,  in  cases  where  it  may  not 
seem  desirable  to  use  the  heavier  foils,  strips  can  be  prepared  by 
folding  the  lighter  foils  and  cutting  them  into  suitable  widths. 
For  instance,  a  sheet  of  l^o.  4  foil  may  be  folded  three  times,  which 
makes  four  layers  of  foil.  This  fold  is  then  cut  into  strips  of  from 
tAvo  to  three  millimeters  in  width,  making  a  very  convenient  prepa- 
ration for  the  rapid  mallet,  tacking  one  end  on  the  filling  and  fold- 
ing it  back  and  forth  across  the  surface  as  it  is  being  condensed. 

For  those  operators  who  do  not  use  the  rapid  mallet  and  who  find 
the  heavier  golds  inconvenient  or  difficult  of  manipulation  for 
surface  work,  the  following  method  of  preparing  the  gold  is 
strongly  advised.  The  folds  just  mentioned  do  not  contain  a  suf- 
ficient number  of  layers  of  foil  to  build  up  with  any  rapidity  under 
the  slower  mallets  such  as  the  hand  mallet  or  the  automatic,  but  the 
order  of  arrangement  of  the  layers  is  good  and  should  be  preserved. 
To  do  this  take  a  whole  sheet  of  No.  4  foil  and  fold  it  once,  having 
the  margins  even  and  the  one  layer  pressed  flat  on  the  other.  Then 
fold  again  in  precisely  the  same  way,  pressing  flat  and  even,  and 
continue  the  folding  till  the  width  of  the  resulting  ribbon  is  about 
five  or  six  millimeters,  or  a  trifle  less  than  a  quarter  of  an  inch. 
This  flat  ribbon  may  then  be  cut  into  strips  from  two  to  six  milli- 
meters wide,  according  to  the  requirements  of  the  case  in  hand. 
Gold  prepared  in  this  way  will  be  found  very  effective  in  securing 
a  uniformly  dense  arid  perfect  wearing  surface  to  fillings.  The 
little  pads  after  annealing  should  be  laid  upon  the  filling  with  their 
sides  flat  against  the  surface  and  in  precisely  the  position  where 
it  is  intended  to  condense  them,  and  each  pad  should  be  thor- 
oughly condensed  before  another  is  added.  Tf  the  final  one-third 
of  the  filling  be  built  up  in  this  way  there  will  be  less  complaint  of 
faulty  surfaces,  both  as  regards  wearing  quality  and  appearance. 

The  form  of  the  different  kinds  of  gold  will  receive  more  de- 
tailed mention  incidentally  with  the  consideration  of  their  intro- 
duction into  the  various  classes  of  cavities. 


172  PEIlSrCIPLES    AND    PRACTICE    OF    PILLING    TEETH. 

Crystal  Golds. 

Crystal  gold  is  prepared  by  precipitating  the  gold  into  crystals 
instead  of  by  beating  it  into  foil.  Its  working  qualities  are  some- 
what different  from  foil,  and  its  characteristics  must  be  well  under- 
stood in  order  to  obtain  good  results.  Some  operators  seem  to 
have  a  peculiar  aptitude  for  manipulating  this  kind  of  gold,  and 
are  able  to  use  it  more  satisfactorily  than  foil,  but  for  the  great 
miajority  of  practitioners  it  can  never  be  relied  upon  to  do  the  same 
service  as  foil  in  the  varying  conditions  presented  in  different 
classes  of  cavities.  Its  main  virtue  lies  in  its  tendency  to  remain 
]3laced  in  the  bottom  of  a  cavity  when  once  forced  there.  It  does 
not  so  readily  curl  away  from  a  wall,  or  rock  under  subsequent 
pressure,  as  does  foil,  and  it  is  therefore  indicated  for  starting  the 
filling  in  those  oases  where  the  best  retentive  form  to  the  cavity  at 
this  point  has  not  seemed  possible  of  attainment.  It  is  also  more 
rapidly  condensed  in  a  cavity,  the  filling  apparently  growing  in 
bulk  at  a  greater  rate  of  speed  under  the  plugger  than  where  foil 
is  used;  but  this  very  rapidity  of  growth  may  prove  an  element  of 
insecurity  in  the  constant  danger  of  bridging  over  spaces  and  leav- 
ing a  filling  imperfect  in  density.  This  may  readily  occur  with  a 
careless  operator,  while  the  surface  of  the  filling  appears  satisf ac- 
tor}'. The  fact  that  large  masses  of  crystal  gold  may  be  inserted 
into  a  cavity  and  matted  down  to  place  with  apparent  ease  is  cal- 
culated to  mislead  many  operators.  These  large  masses  behave 
much  like  wet  snow  under  pressure, — they  condense  on  the  surface 
but  are  inclined  to  remain  porous  in  the  depth  of  the  mass.  In 
order  to  accomplish  good  results  with  crystal  gold,  and  do  justice 
to  the  material,  the  very  greatest  care  must  be  used  in  its  manipu- 
lation. It  will  not  tolerate  the  range  of  usage  that  will  foil,  and 
unless  an  operator  is  prepared  to  give  a  careful  study  to  its  peculiar 
requirements  he  would  better  not  employ  it..  The  chief  distinction 
in  this  connection  between  foil  and  crystal  gold  is  that  foil  demands 
care,  and  so  expresses  itself  at  every  turn,  while  the  other  den?iands 
equal  or  greater  care,  but  seems  constantly  to  give  the  impression 
that  it  does  not. 

As  to  the  form  of  crystal  gold  best  adapted  for  serviceable  work. 


GOLD.  173 

those  preparations  in  which  the  deposit  has  been  carried  on  long 
enough  at  one  time  to  produce  crystals  or  spiculse  of  considerable 
length  would  seem  to  offer  the  greatest  pi-omise  of  usefulness,  both 
as  to  strength  of  the  finished  product  and  convenience  of  manipula- 
tion. A  mat  of  gold  formed  of  small  crystals  is  granular  in  struc- 
ture. It  is  easily  disintegrated  in  handling,  and  crumbles  so  as  to 
waste  extensively;  while  a  filling  made  from  it  cannot  be  expected 
to  present  the  same  strength  in  a  given  mass  that  would  one  made 
from  gold  of  a  more  fibrous  nature.  Another  important  considera- 
tion in  this  connection  is  that  a  fibrous  gold  may  be  expected  to 
result  in  better  margins  to  the  filling  than  one  of  a  granular  struc- 
ture. One  serious  limitation  to  some  of  the  crystal  golds  offered 
in  the  past  has  been  the  insecurity  of  the  material  when  built  over 
beveled  enamel-margins,  on  account  of  the  tendency  to  disintegrate 
and  crumble  away.  The  more  perfectly  the  fibrous  arrangement 
is  maintained,  the  greater  strength  may  be  expected  of  the  material. 
Recent  improvements  along  this  line  in  the  manufacture  of  crystal 
golds  would  seem  to  promise  an  increased  usefulness  for  them  in 
practice,  but,  as  already  intimated,  no  operator  should  employ 
them  without  a  perfect  understanding  of  their  peculiarities. 

The  main  points  to  be  considered  in  manipulating  crystal  gold 
relate  to  accuracy  in  placing  each  pellet  as  it  is  carried  to  the 
cavity,  to  a  careful  selection  of  the  cases  suitable  for  its  use,  and 
to  the  proper  form  of  plugger-points.  Each  piece  of  gold  should 
be  carried  precisely  to  the  spot  where  it  is  intended  to  condense  it, 
and  it  sliould  not  be  disturbed  by  too  much  manipulation  before  it 
is  condensed.  It  is  quite  impossible,  with  crystal  gold  of  good 
cohesive  texture,  to  move  a  pellet  of  it  across  the  surface  of  the 
^old  already  in  the  cavity  for  the  purpose  of  securing  a  more  con- 
venient position.  Any  attempt  to  insinuate  it  out  of  the  location 
first  taken  willresult  in  tearing  the  uncondensed  pellet  so  that  it 
is  disintegrated  and  wasted. 

The  places  where  crystal  gold  is  indicated  are  in  starting  fillings 
in  difficult  cases,  and  in  large,  open  cavities  easy  of  access,  where 
The  gold  may  be  conveniently  laid  on  in  regular  arrangement  and 
condensed  under  the  eye  of  the  operator.     It  should  not  be  em- 


t^ 


174  PRINCIPLES    AXD    PKACTICE    OF    FILLIXG    TEETH. 

l^loyed  for  filling  undercuts  or  remote  positions  in  cayities,  on 
account  of  the  tendency  to  bridge. 

The  pluggers  best  adapted  to  its  use  are  the  oval-faced  forms, 
with  shallow  serrations.  For  starting  the  filling  a  large  point 
should  be  used,  with  vigorous  hand-pressure,  to  carry  the  mass  in 
front  of  the  plugger  instead  of  puncturing  it;  but  as  the  filling  is 
being  built  up  too  large  points  must  not  be  used,  for  fear  of  failure 
in  density.  A  convenient  method  of  condensing  the  main  portion 
of  the  filling  and  securing  an  even  surface  is  to  use  a  rapid  mallet 
with  the  Royce  plugger-points.  These  points,  being  oval  on  their 
serrated  ends,  may  be  swept  back  and  forth  across  the  surface 
of  the  filling  with  little  danger  of  tearing  the  uncondensed  gold 
away  and  wasting  it,  as  is  sometimes  the  result  with  flat-faced  plug- 
gers. The  Royce  pluggers  should  be  held  a  short  distance  from 
the  condensed  surface,  so  that  the  jump  of  the  mallet  catches  the 
gold  in  front  of  the  plugger  and  mats  it  to  place. 


CHAPTER    VI 11. 

MALLETS  AND  MALLETIjSTG. 

The  selection  of  a  mallet  for  the  insertion  of  gold  is  a  matter 
which  must  be  left  largely  to  the  individual  preference  of  the 
operator,  and  yet  there  are  distinguishing  characteristics  related  to 
the  different  forms  of  mallet  which  call  for  consideration.  Laying 
aside  the  factor  of  personal  equation,  we  must  not  ignore  some  of 
the  fundamental  qualities  inherent  in  the  nature  of  the  appliance 
which  influence  its  practical  utility. 

The  Hand  Mallet. 

This  mallet  was  the  first  to  be  used  for  condensing  gold,  and  it 
would  seem  to-day  to  be  capable  of  a  wider  range  of  service  than 
any  other  single  form  of  mallet.  Xo  other  mallet  yet  suggested 
has  so  many  advantages  with  so  few  disadvantages.     Its  chief  limi- 


MALLETS    AND    MALLETIXG.  IT 5 

tatiou  relates  to  the  necessity  of  employing  an  assistant  to  manipu- 
late it,  owing  to  the  fact  that  the  operator  has  too  many  uses  for 
his  left  hand  to  make  it  convenient  for  him  to  employ  it  for  this 
purpose.  It  is  true  that  some  practitioners  prefer  to  do  their  own 
malleting,  and  by  constant  practice  become  very  expert,  but  in  the 
daily  routine  of  gold  filling  there  are  too  many  demands  on  an 
operator's  vitality  "without  adding  to  them  in  this  particular.  !N"o 
operator  can  do  his  own  malleting  without  placing  himself  in  a 
more  strained  position  than  would  be  necessary  if  some  one  else 
malleted,  and  there  are  times  when  it  seems  almost  imperative  to 
utilize  both  hands  for  other  purposes.  While  it  may  be  possible 
to  strike  a  more  intelligent  blow^  and  regulate  the  force  more 
accurately  to  the  requirements  of  the  case,  yet  the  method  calls  for 
too  great  a  tax  on  the  operator  to  make  it  desirable  practice. 

The  Assistant. — The  problem  of  training  an  assistant  to  be  a 
good  malleter  is  a  necessary  concomitant  to  success  in  the  use  of  the 
hand  mallet.  ITsually  a  young  lady  assistant  is  best  suited  to  this 
purpose, — one  who  has  no  intention  of  studying  dentistry  as  a 
profession.  The  reason  for  this  is  that  to  be  an  expert  malleter 
the  assist-ant  should  have  no  interest  in  the  operation  except  to  use 
the  mallet.  A  student  of  dentistry  naturally  becomes  interested  in 
the  progress  of  the  filling,  and  is  inclined  to  divert  the  attention 
occasionally  to  the  tooth  instead  of  concentrating  it  solely  upon  the 
end  of  the  phigger  handle.  This  diversion  results  in  imperfect 
work,  and  any  imperfection  on  the  part  of  the  assistant  renders 
the  hand  mallet  almost  the  worst  that  can  be  used.  The  quickest 
perception  is  necessary  to  anticipate  every  move  of  the  operator, 
and  a  young  lady  usually  possesses  this  intuitive  perception  to  a 
greater  degree  tlian  the  average  young  man.  A  nod  of  the  opera- 
tor's head  or  the  slightest  intimation — so  slight,  in  fact,  that  the 
patient  need  never  be  cognizant  of  it — is  all  that  should  be  neces- 
sary to  indicate  to  a  capable  assistant  the  character  of  bloAV  re- 
quired, whether  as  to  force  or  rapidity  of  stroke.  The  assistant 
should  be  trained  to  develop  the  wrist  to  the  highest  degree  of 
suppleness,  so  tliat  in  striking  the  blow  there  shall  be  an  entire 
absence  of  arm-weight  exerted  upon  the  nudlet.     She  should  also 


176  PRINCIPLES    AND    PBACTICE    OF    FILLING    TEETH. 

learn  to  use  either  hand  with  equal  facility,  but  in  the  event  of  one 
hand  being  developed  to  a  higher  degree  of  perfection  than  the 
other,  preference  should  be  given  to  the  left  hand,  on  account  of 
the  fact  that  during  most  operations  the  assistant  must  stand  on  the 
left  side  of  the  patient,  facing  the  operation,  thus  giving  the  left 
hand  the  widest  range  of  usefulness. 

One  of  the  most  important  considerations  in  the  use  of  the  hand 
mallet  relates  to  the  angle  at  which  the  mallet  meets  the  plugger. 
The  striking  face  of  the  mallet  should  be  at  direct  right  angles 
wdth  the  long  axis  of  the  plugger,  or,  in  other  words,  the  mallet 
should  strike  the  plugger  squarely  on  the  end  at  every  blow.  Any 
deviation  from  this  results  in  a  gliding  of  the  mallet  across  the  end 
of  the  plugger,  which  interferes  with  its  condensing  power  and 
proves  very  distressing  to  the  patient.  To  invariabfy  strike  a 
square  blow  necessitates  the  constant  attention  of  the  assistant, 
added  to  a  quick  anticipation  of  any  change  in  the  angle  made  by 
the  operator,  so  as  to  meet  it  with  a  corresponding  change  in  the 
direction  of  the  mallet  blow.  There  should  be  developed  between 
the  operator  and  malleter  the  closest  concert  of  action,  and  the 
one  should  understand  the  methods  of  the  other  so  perfectly  that 
no  verbal  instruction  is  necessary  during  an  operation.  This  har- 
mony of  procedure  is  very  reassuring  to  a  patient  and  leads  to  confi- 
dence in  both  operator  and  assistant. 

The  Kind  of  Mallet. — Various  forms  of  hand  mallets  have  been 
devised  with  the  idea  of  finding  something  which  was  alike  agree- 
able to  the  patient  and  effective  in  condensing  power.  The  steel 
mallet  has  probably  been  more  universally  used  than  any  other, 
and  while  to  some  patients  objectionable  on  account  of  the  hard 
metallic  ring  to  the  blow,  it  still  possesses  characteristics  which 
make  it  a  very  desirable  form  of  mallet.  By  its  use  an  intelligent 
operator  can  detect  instantly  when  his  gold  is  dense  under  the 
plugger-point.  There  is  something  which  telegraphs  to  the  hand 
holding  the  plugger  a  sense  of  solidity  to  the  filling  the  moment 
this  solidity  is  reached,  and  distinguishes  perfectly  between  a  sur- 
face partially  condensed  and  one  completely  condensed.  This 
nicety  of  distinction  is  scarcely  to  be  attained  by  any  other  form 


MALLETS    AXD    MALLETING.  177 

of  mallet,  such  as  those  made  of  lead  or  lead  covered  with  leather. 
These  have  a  dead  soft  blow  more  acceptable  to  most  patients, 
but  requiring  in  the  aggregate  a  large  number  of  blows  for  a  given 
density,  or  at  least  a  larger  number  before  the  operator  can  be 
assured  of  density.  One  very  great  advantage  of  the  softer  mal- 
lets is  that  a  much  heavier  mallet  can  be  tolerated  by  the  patient 
than  if  made  of  steel,  and  the  condensing  power  is  thereby  ma- 
terially increased  without  discomfort.  The  operator  should  make  a 
careful  study  of  these  two  forms  of  mallets  with  the  view  of  em- 
ploying the  particular  kind  which  seems  the  most  effective  in  his 
hands  with  the  least  accompanying  pain  to  the  patient. 

The  wooden  mallet  used  by  some  operators  is  ill  adapted  to  the 
purpose  of  condensing  gold.  Unless  it  is  so  large  as  to  be  un- 
wieldy, it  has  not  sufficient  weight  to  be  effective,  and  in  order  to 
gain  anything  approaching  adequate  density  it  requires  so  many 
bloAvs  that  the  process  becomes  exceedingly  irksome  to  the  patient. 
It  is  not  only  inefficient,  but  is  objectionable  in  point  of  comfort. 

The  Automatic  Mallet. 
This  mallet  was  devised  to  avoid  the  necessity  of  employing  an 
assistant,  and  in  the  hands  of  some  operators  it  seems  to  be  ai> 
efficient  appliance.  But  it  may  well  be  doubted  whether  it  is  ever 
capable  of  the  same  degree  of  delicacy  that  is  easily  attained  with 
the  hand  mallet,  or  whether  for  most  patients  it  can  be  compared 
to  the  hand  mallet  when  comfort  is  considered.  Given  an  expert 
assistant  in  a  test  of  the  two  forms  of  mallets,  and  probably  nine 
out  of  ten  patients  will  select  the  hand  mallet.  There  is  a  feature 
of  the  automatic  mallet  which  doubtless  may  be  held  in  some  de- 
gree accountable  for  this  aversion  on  the  part  of  patients.  In 
order  to  obtain  the  blow  it  is  necessary  to  exert  pressure  on  the 
filling  with  the  plugger-point,  and  this  pressure  carried  to  a  certain 
limit,  causing  a  sudden  recoil  and  blow,  creates  in  the  mind  of  the 
patient  a  series  of  anticipations  which  in  the  aggregate  become 
exhausting.  In  other  words,  the  patient  is  continually  being 
warned  by  the  pressure  that  a  blow  is  to  be  struck,  and  this  re- 
peated leading  up  to  the  bloAV  by  pressure  keeps  the  patient  con- 

12 


1Y8  PKINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

stantly  on  a  tension.  The  precise  character  of  the  discomfort  is 
not  always  capable  of  analysis  by  patients,  and  they  are  often 
unable  to  explain  why  they  dislike  the  automatic  mallet,  but  if 
this  matter  be  carefully  watched  by  the  operator  he  will  soon  ascer- 
tain that  there  is  invariably  an  intuitive  flinching  on  the  part  of 
the  patient  whenever  the  pressure  of  the  plugger  is  prolonged 
beyond  the  ordinary.  It  seems  to  be  this  interval  of  suspense 
which  is  trying  to  the  patient  more  than  the  actual  blow.  All  of 
this  is  avoided  by  the  hand  mallet.  There  is  no  advance  pres- 
sure to  herald  the  coming  blow,  and  the  character  of  the  stroke 
is  short,  sharp,  decisive,  and  instantly  over  with. 

This  recalls  one  feature  of  an  automatic  which  would  seem  to 
have  an  important  bearing  on  its  utility.  The  stroke  should  be 
as  short  as  possible  consistent  with  volume  of  blow.  Most  auto- 
matic mallets  have  so  long  a  stroke  that  their  manipulation  is  a 
slow  and  awkward  process,  besides  adding  materially  to  the  ele- 
ment of  discomfort.  An  automatic,  to  do  the  best  service  capable 
of  such  an  instrument,  should  work  with  a  short,  snappy  blow, 
definite  in  quality  and  with  a  rapid  rebound,  so  as  never  to  miss  a 
stroke.  To  attain  this  the  appliance  must  be  kept  in  the  most 
perfect  condition  by  repeated  cleansing  and  oiling. 

The  Rapid  Mallets. 

Each  of  the  various  forms  of  rapid  mallets  has  its  adherents 
among  operators,  but  probably  the  ones  most  in  use  to-day  are  the 
mechanical  or  pneumatic  mallets  operated  by  the  engine  or  by  a 
motor.  The  electric  mallet  seems  largely  to  have  been  displaced 
in  recent  years  by  others  more  readily  kept  under  control  and  less 
complicated.  It  would  seem  that  the  ideal  rapid  mallet  was  one 
which,  besides  giving  a  definite  blow  at  any  desired  speed,  may  be 
run  by  the  motor.  To  operate  a  mallet  with  the  foot  engine  be- 
comes wearisome  in  a  long  sitting. 

The  only  places  suited  for  a  rapid  mallet  are  in  cavities  ready  of 
access,  where  it  is  merely  a  matter  of  laying  on  the  gold,  and  also 
for  finishing  the  surfaces  of  fillings  after  the  inaccessible  parts  of 
the  cavity  have  been  filled.     It  is  hazardous  to  attempt  to  build 


MALLETS    AND    MALLETING,  179 

gold  around  corners  or  to  reach  difficult  positions  with  the  rapid 
mallet.  Such  an  effort  usually  results  in  bridging  the  gold  over 
spaces,  and  fails  in  perfect  protection  of  cavity-walls  in  the  inacces- 
sible regions. 

It  is  often  an  agreeable  change  for  the  patient  to  have  the  rapid 
mallet  substituted  for  the  hand  or  automatic  mallet  as  the  filling 
nears  completion.  Any  diversion  in  the  character  of  the  blow 
seems  to  afford  relief  from  the  monotony  of  a  long  sitting,  and  to 
be  more  acceptable  to  most  patients  than  the  continued  use  of  any 
one  kind  of  blow  throughout  the  entire  filling.  For  this  purpose 
the  rapid  mallet  becomes  very  useful,  and  it  also  materially 
shortens  the  operation.  Gold  may  be  condensed  on  an  accessible 
surface  almost  as  rapidly  as  the  pellets  can  be  carried  to  the  tooth 
and  placed  by  the  assistant.  This  mallet  also  leaves  a  surface  even 
and  dense,  if  its  manipulation  be  well  understood. 

The  proper  method  of  using  a  rapid  mallet  is  to  sweep  the 
plugger  point  across  the  surface  of  the  filling  from  center  to  mar- 
gin, as  if  the  gold  were  being  wiped  into  the  cavity.  The  process 
is  entirely  different  from  that  of  the  hand  or  automatic  mallet,  and 
this  fact  should  be  recognized  by  those  who  attempt  to  use  it. 

As  before  intimated,  oval-faced  pluggers  with  shallow  serrations 
are  indicated  for  the  rapid  mallet,  whereby  the  gold  may  be  wiped 
down  on  the  filling  instead  of  being  caught  by  the  side  of  the 
plugger  and  torn  off  laterally,  as  would  be  likely  to  result  with  a 
flat-faced  plugger  having  a  sharp  angle  between  the  serrated  end 
and  the  shank.  Another  advantage  of  oval-faced  pluggers  relates 
to  the  safety  of  enamel-margins.  The  rapid  mallet  carrying  a 
plugger  with  sharp  angles  is  exceedingly  prone  to  chop  up  or 
pulverize  the  margins  unless  the  greatest  care  is  exercised,  but  the 
oval-faced  pluggers  will  permit  greater  freedom  of  action  without 
injury.  This  watchful  care  of  the  enamel-margins  is  one  of  the 
necessary  precautions  in  the  use  of  any  rapid  mallet,  and  no  opera- 
tor should  attempt  to  use  such  an  appliance  without  due  apprecia 
tion  of  its  dangers  in  this  respect. 


180  PKINCIPLES    AND    PBACTICE    OF    FILLING    TEETH. 

Hand  Pressure. 

If  an  operator  were  rigidly  confined  to  any  one  process  for  the 
insertion  of  gold,  it  is  probable  that  he  would  do  better  service  for 
his  patient  in  the  varying  conditions  presented  in  the  mouth  by 
the  use  of  hand  pressure  than  by  any  other  one  method,  and  yet 
the  places  where  hand  pressure  is  properly  indicated  are  compara- 
tively limited.  The  great  bulk  of  our  work  is  better  accomplished 
by  mallet  force,  but  in  those  occasional  locations  demanding  hand 
pressure  there  seems  to  be  nothing  else  which  will  at  all  adequately 
take  its  place.  In  distal  cavities  in  molars  and  bicuspids  there  is 
often  a  certain  region  which  cannot  be  reached  by  a  direct  blow 
of  the  mallet,  and  unless  the  operator  recognizes  this  fact  and  re- 
sorts to  hand  pressure  in  building  up  the  filling  at  these  points  he 
will  fail  of  perfect  protection  tO'  the  cavity-walls.  These  inacces- 
sible locations  are  usually  represented  by  the  wall  of  the  cavity 
which  stands  nearest  to  the  operator,  or,  in  other  words,  whose 
face  is  presented  away  from  the  operator  so  that  it  cannot  be  seen 
except  with  a  mirror. 

For  instance,  in  a  disto-occlusal  cavity  on  a  right  lower  molar 
the  buccal  wall  of  the  cavity  can  seldom  be  seen  by  the  unaided 
eye,  and  the  relation  of  the  operator  to  this  wall  is  such  that  direct 
mallet  force  against  it  is  impossible.  In  a  case  like  this  the  only 
certain  means  of  securing  adaptation  of  the  gold  to  the  wall  is  by 
the  use  of  right-angle  pluggers  wielded  by  hand  pressure.  When 
these  cavities  are  on  the  distal  surfaces  of  teeth  far  back  in  the 
mouth,  or  where  the  muscles  of  the  lips  are  tense  and  unyielding, 
it  is  often  necessary  to  build  the  entire  gingival  third— or  even 
half' — of  the  filling  by  hand  pressure. 

The  right-angle  mallets  devised  as  a  substitute  in  the  various 
cases  indicated  are  useful  in  the  hands  of  some  operators  under 
certain  conditions,  but  it  would  seem  impossible  to  get  so  accurate 
a  placing  of  the  gold  by  their  use  as  by  hand  pressure.  The  gold 
can  be  "pulled"  against  inaccessible  places  or  insinuated  under 
overhanging  walls  where  such  conditions  are  encountered  with 
greater  precision  by  hand  pressure  than  by  any  mallet  force.  The 
pluggers  used  for  the  purpose  should  have  a  very  stiff  shank  with 


MALLETS    AND    MALLETING.  '  ISl 

a  large  handle,  capable  of  being  conveniently  grasped  in  the  palm, 
by  which  means  most  of  the  pulling  force  is  best  exerted.  In  order 
to  be  assured  of  perfect  adaptation  and  an  adequate  degree  of 
density  with  hand  pressure,  it  is  necessary  to  exert  considerable 
force,  and  the  plugger  should  be  strong  and  the  wall  sufficiently 
thick  to  safely  sustain  this  force.  This  recalls  a  certain  mistaken 
idea  which  appears  to  be  prevalent  among  operators  as  to  the 
indications  for  and  against  hand  pressure.  The  impression  would 
seem  to  prevail  that  hand  pressure  is  indicated  when  building  along 
frail  walls  or  over  friable  enamel.  The  exact  contrary  is  the 
fact.  Xo  operator  can  with  hand  pressure  secure  the  same  de- 
gree of  density  or  adaptation  along  weak  walls  that  can  safely  be 
obtained  by  delicate  blows  of  the  mallet.  This  is  particularly  true 
of  the  hand  mallet  wielded  by  a  trained  assistant. 

One  place  where  hand  pressure  is  useful  relates  to  the  starting 
of  all  fillings.  This  can  be  readily  accomplished  on  the  wedging 
principle  with  non-cohesive  gold,  and  the  first  pieces  of  cohesive 
gold  may  also  be  carried  to  place  and  fastened  into  the  substance 
of  the  non-cohesive  to  the.  best  advantage  with  hand  pressure. 
For  this  purpose  a  certain  manner  of  manipulating  the  plugger 
should  be  observed,  in  order  to  obtain  the  most  perfect  results. 
It  is  seldom  that  a  straight  pushing  or  pulling  force  will  prove  as 
effective  as  will  the  same  degree  of  force  exerted  with  a  wrist  move- 
ment whereby  the  point  of  the  plugger  is  held  on  the  gold  and  the 
end  of  the  handle  is  swayed  back  and  forth  so  as  to  describe  the 
short  arc  of  a  circle,  If  a  right-angle  plugger  is  being  used,  the 
swaying  should  occur  at  the  angle.  This  insinuating  spreading 
force  accomplishes  two  objects:  it  carries  the  gold  into  every  in- 
equality in  the  wall  of  the  cavity,  securing  perfect  adaptation,  and 
the  swaying  motion  also  presses  the  uncondensed  portion  of  the 
pellet  which  has  curled  up  around  the  shank  away  from  the  plug- 
ger, allowing  the  instrument  to  be  withdrawn  without  carrying 
the  pellet  with  it. 

This  same  mctlMxl  of  iiiuiiii)idatioii  is  very  effective  when  for 
any  reason  not  apparent  to  the  operator  a  pellet  of  gold  fails  to 
adhere  to  the  surface  of  tlic  filling  under  mallet  force.     A  rebel- 


182  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

lions  pellet  may  be  fastened  to  the  filling  by  hand  pressure  exerted 
as  jnst  indicated,  and  made  to  remain  more  securely  than  by  mallet 
force.  The  rocking  motion  of  the  plugger  insinuates  the  substance 
of  the  loose  pellet  into  the  structure  of  the  condensed  gold  and  pins 
it  to  place  to  better  advantage  than  if  the  mere  property  of  sur- 
face cohesion  were  the  sole  dependence.  For  this  purpose  a  plug- 
ger point  with  clean-cut,  sharp  serrations  is  indicated,  and  after 
several  pieces  have  been  added  to  the  filling  in  this  way  it  should 
be  followed  by  the  mallet  over  the  surface  to  insure  uniformity  of 
density. 

It  may  be  here  stated  that  a  more  satisfactory  wearing  surface 
can  be  given  to  any  filling  with  mallet  force  than  is  possible  with 
hand  pressure,  though  hand  pressure  fillings  properly  inserted 
usually  succeed  in  saving  the  teeth.  They  do  so  by  reason  of  good 
adaptation  to  the  cavity-walls,  thus  preventing  leakage,  even  in 
many  cases  where  the  wearing  surface  of  the  filling  becomes  pitted 
and  unsatisfactory.  'No  filling  which  is  subjected  to  the  attrition 
of  mastication  should  be  considered  safe,  so  far  as  the  condition  of 
its  surface  is  concerned,  unless  the  mallet  has  been  employed  in 
finishing  the  filling  to  impart  a  resisting  property  to  the  gold. 

Protection  to  the  Peridental  Membrane  in  Malleting. 

The  problem  of  securing  sufficient  density  to  a  gold  filling  so 
that  it  may  safely  withstand  the  usage  to  which  it  is  subjected  in 
the  mouth  without  causing  too  much  punishment  to  the  peridental 
membrane  during  the  operation,  is  one  which  confronts  the  prac- 
titioner on  approaching  any  cavity  of  considerable  size.  The  peri' 
dental  membrane  is  more  or  less  elastic,  and  when  a  blow  is  struck 
on  the  tooth  with  a  mallet  the  tooth  is  forced  slightly  into  the 
alveolus,  causing  a  compression  of  the  membrane.  Instantly  fol- 
lowing this  impact  the  membrane  reasserts  itself,  forcing  the  tooth 
out  again  to  its  original  position.  Another  blow  drives  it  against 
the  membrane  once  more,  and  the  membrane  again  reacts.  This 
repeated  forcing  in  and  out  of  the  tooth  soon  results  in  such  im- 
pairment of  the  membrane  that  if  the  process  is  kept  up  sufficiently 


MALLETS    A^'D    MALLETI>Xt.  183 

long  without  protection  the  operator  is  finally  pounding  the  tooth 
on  a  jellied  membrane. 

This  stage  of  injury  is  reached  much  sooner  in  those  cases  where 
the  teeth  have  recently  been  wedged  apart  and  are  correspondingly 
loose,  and  this  one  factor  becomes  an  important  consideration  in 
the  choice  of  methods  for  gaining  space  as  between  previous  wedg- 
ing and  the  use  of  a  separator.  AVherever  sufficient  space  can  be 
safely  gained  with  a  separator  it  will  ordinarily  result  in  less  aggre- 
gate discomfort  to  the  patient  than  will  the  process  of  previous 
wedging  followed  by  an  operation  while  the  tooth  is  still  loose. 
One  important  ofiice  of  the  separator  is  to  hold  the  tooth  firm 
against  movement  under  the  impact  of  the  mallet,  and  it  may  often 
be  profitably  employed  during  an  operation  for  this  purpose  alone 
in  cases  wliere  space  has  previously  been  gained  by  wedging.  In 
those  instances  where  it  has  been  necessary  to  wedge  extensively 
tlius  causing  so  great  a  movement  of  the  teeth  that  they  are  left 
loose  and  sore,  the  operation  of  filling  should  invariably  be  de- 
ferred till  the  soreness  subsides.  The  teeth  may  be  held  apart  dur- 
ing this  interval  with  gutta-percha. 

The  whole  problem  of  protecting  the  membrane  against  injury 
from  mallet  force  relates  to  giving  the  tooth  such  support  that  it 
is  held  firm  and  immovable  under  the  blow.  This  may  be  ac- 
complished in  various  ways,  each  case  suggesting  the  method 
most  suited  to  itself.  Sometimes  a  wooden  wedge  may  be  used  for 
this  purpose,  or  a  separator  as  already  indicated,  but  for  an  ex- 
tended operation  the  surest  means  is  to  hold  an  instrument  in  the 
left  hand  braced  firmly  against  the  tooth  or  filling  throughout  the 
operation.  This  kind  of  support  is  especially  indicated  as  the  fill- 
ing nears  completion  on  account  of  the  tendency  to  soreness  at  that 
time,  and  also  l>ecause  the  surface  of  the  filling  requires  the  most 
thorough  malleting  to  be  assured  of  adequate  density.  If  a  tooth 
be  protected  in  this  way  the  membrane  will  ordinarily  not  rebel 
against  mallet  force  sufficient  to  condense  gold  into  a  serviceable 
filling,  except  in  those  cases  where  the  membrane  is  impaired 
or  is  hypersensitive.  When  a  tooth  is  loose  from  absorption  of 
the  alveolar  process  or  from  inflammation  of  the  soft  parts  sur- 


184  PKINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

rounding  it,  a  gold  filling  of  any  size  should  not  be  attempted  in  it 
till  the  tooth  is  made  firm  by  treatment.  If  it  cannot  be  made  firm 
the  operator  would  better  select  some  other  filling-material. 

In  some  instances  the  peridental  membrane  is  so  weakened 
through  lack  of  use  that  it  is  painfully  responsive  to  mallet  force. 
This  is  ordinarily  brought  about  by  the  fact  that  when  caries 
occurs  the  tooth  becomes  sensitive  to  mastication,  and  the  patient 
involuntarily  avoids  its  use  to  the  end  that  the  membrane,  lacking 
its  normal  functional  exercise,  deteriorates  in  its  resistive  qualities 
so  as  to  quickly  rebel  against  the  mallet.  The  remedy  for  thia 
condition  lies  in  subjecting  the  tooth  to  masticatory  usage  in  ad- 
vance of  the  operation,  by  placing  in  the  cavity  a  gutta-percha  plug 
to  control  the  sensitiveness  and  instructing  the  patient  to  bring  the 
tooth  into  active  service.  In  this  way  the  membrane  may  be  so 
toughened  in  a  week  or  ten  days  as  to  receive  the  impact  of  the 
mallet  comfortably. 

Another  consideration  connected  with  the  toleration  of  the  mem^ 
brane  to  mallet  force  relates  to  the  direction  in  which  the  pressure 
is  brought  to  bear  upon  the  tooth.  If  the  condensation  of  the 
gold  takes  place  in  line  with  the  length  of  the  root,  it  will  be  found 
that  there  is  less  soreness  than  where  an  equal  force  is  exerted 
against  the  tooth  laterally.  With  this  idea  in  mind,  all  fillings 
requiring  extended  malleting  should  be  so  built,  if  possible,  that 
the  pellets  of  gold  are  laid  at  right  angles  to  the  long  axis  of  the 
tooth  and  the  plugger  held  parallel  with  this  axis.  When  a  blow 
is  struck  in  this  direction  the  force  is  distributed  throughout  the 
entire  surface  of  the  membrane  instead  of  being  exerted  against 
only  one  side  of  the  root,  as  would  result  if  a  blow  were  struck  at 
right  angles  to  any  of  the  axial  surfaces.  There  are,  of  course, 
instances  where  lateral  force  must  be  employed,  but  these  are 
usually  in  fillings  of  limited  area  where  the  aggregate  mallet  force 
is  not  sufficient  to  leave  any  serious  impress  upon  the  membrane. 


IXTRODUCTIOX    AXD    FINISHING    OF    GOLD    FILLINGS.  185 

CHAP  TEE    IX. 

THE  INTRODUCTION,  CONDENSATION,  AND  FINISHING  OF  GOLD 
FILLINGS  IN  THE  DIFFERENT  CLASSES  OF  CAVITIES. 

AVhile  each  cavity  is  to  a  certain  degree  a  law  unto  itself  so  far 
as  the  manner  of  building  the  filling  is  concerned,  yet  there  are 
fundamental  principles  of  procedure  which  if  intelligently  recog- 
nized will  render  the  work  more  systematic  and  satisfactory.  The 
methods  herein  suggested  are  not  always  applicable  l)ecause  of  the 
constant  occurrence  of  cavities  unique  in  location  and  form,  but 
for  the  so-called  typical  cavities  of  the  different  classes  it  is  believed 
that  if  intelligently  followed  they  will  at  least  prove  effective  in  the 
accomplishment  of  satisfactory  work. 

The  arrangement  in  the  cavity  of  the  layers  of  foil  constituting 
a  pellet  becomes  a  matter  of  some  importance  in  its  relation  to 
the  symmetrical  growth  of  the  filling  under  the  plugger,  and  also 
to  its  resultant  strength.  It  is  with  this  idea  in  mind  that  the 
present  plans  of  procedure  have  been  suggested,  as  well  as  on  the 
basis  of  expediency  in  the  manner  of  building  the  filling. 

To  start  any  filling  a  rope  of  non-cohesive  gold,  varying  in  size 
as  indicated  by  the  requirements  of  the  case,  will  be  found  effective. 
A  convenient  form  may  be  made  as  follows:  Divide  a  sheet  of 
Xo.  4  foil  twice,  making  one-third  of  a  sheet;  then  roll  into  a  rope 
about  the  size  of  a  large  knitting  needle,  and  cut  the  rope  in  three 
parts.  This  makes  a  rope  approximately  an  inch  in  length,  and 
of  a  size  that  can  be  readily  carried  into  most  cavities  of  any 
extent.  In  small  cavities  the  rope  may  be  cut  short  enough  for 
convenience. 

When  starting  a  filling  the  rope  should  be  grasped  by  the  pliers 
about  one-fourth  of  an  inch  from  the  end,  and  this  end  carried  into 
the  angle  of  the  cavity  where  it  is  intended  to  commence  the  filling. 
The  rope  will  fohl  upon  itself  as  it  is  pressed  into  the  angle,  so  that 
it  will  remain  there  while  the  pliers  release  it  and  grasp  it  farther 
back  and  fold  it  once  more  into  the  cavity.  This  process  is  kept  up 
till  the  entire  rope  is  carried  into  position,  where  it  may  be  con- 


186  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

densed  in  the  manner  to  be  described  when  considering  the  details 
of  filling  building  in  the  different  cavities.  Into  the  structure  of 
this  non-cohesive  cushion  may  be  wedged  the  first  pellets  of  co- 
hesive gold  till  the  two  forms  of  gold  are  so  interlocked  that  they 
will  not  separate,  when  the  filling  may  be  completed  Avith  cohesive 

gold. 

Simple  Proximal  Fillings  in  Incisors. 

These  fillings,  when  built  from  the  labial  aspect,  are  ordinarily 
best  started  in  the  gingivo-linguo-axial  angle  of  the  cavity  by  carry- 
ing a  rope  of  non-cohesive  gold  into  this  angle  as  already  indicated. 
The  rope  should  be  folded  upon  itself  from  the  starting  point  along 
the  gingival  wall  toward  the  labial  wall,  till  it  is  securely  locked 
between  the  gingival  third  of  the  labial  and  lingual  walls.  If  the 
gingival  wall  has  been  made  fiat  there  will  be  little  difficulty  in 
securing  the  rope  in  place.  The  first  rope  used  should  be  of  suffi- 
cient size  to  cover  the  entire  gingival  wall  from  lingual  to  labial, 
and  extend  well  over  the  gingival  enamel-margin.  The  office  of 
this  rope  is  to  secure  ready  adaptation  to  the  angles  of  the  cavity, 
and  also  to  form  a  non-cohesive  cushion  against  which  cohesive 
gold  may  be  condensed  without  danger  of  injury  to  the  gingival 
enamel-margin.  In  condensing  gold  over  margins  it  should 
always  be  a  cardinal  principle  to  keep  a  sufficient  mat  of  gold  be- 
tween the  plugger  point  and  the  margin  to  avoid  the  possibility  of 
injuring  the  enamel  with  the  serrations  of  the  plugger. 

When  the  non-cohesive  rope  has  been  carried  to  place  with  the 
pliers  it  should  be  more  securely  locked  in  position  by  bringing  a 
plugger  to  bear  on  it  at  two  or  three  points  with  hand  pressure, 
Avielded  in  the  rocking  motion  already  described.  The  first  direc- 
tion of  the  plugger  should  be  toward  the  gingivo-linguo-axial 
angle,  and  the  gold  should  be  wedged  into  this  angle  with  con- 
siderable force.  If  the  rocking  motion  of  the  plugger  is  used  the 
gold  can  be  so  locked  into  place  as  not  to  be  readily  moved  by 
subsequent  manipulation,  but  if  there  seems  any  doubt  about  its 
security  a  retaining  instrument  may  be  placed  on  the  condensed 
gold  the  moment  the  plugger  is  withdrawn,  and  held  there  while 
the  locking  process  is  carried  on  by  the  plugger  at  other  points. 


IXTKODUCTIOX    AND    FINISHING    OF    GOLD    FILLINGS.  187 

The  next  direction  of  the  pkigger  should  be  toAvard  the  gingivo-- 
labio-axial  angle,  and  these  two  points  may  be  all  that  is  necessary 
to  condense  at  this  time.  The  object  is  simply  to  lock  the  rope  into 
the  angles  of  the  cavity  rather  than  to  attempt  the  condensation 
of  the  entire  mass.  In  fact,  too  much  condensation  must  be 
avoided  until  some  cohesive  gold  has  been  called  into  service. 
After  the  plugger  is  withdrawn  from  the  gingivo-labial  angle  a 
cohesive  cylinder  sufficiently  large  to  cover  the  entire  gingivo- 
lingual  region  should  be  laid  with  its  side  upon  the  non-cohesive 
gold,  and  one  end  looking  along  the  lingual  wall  and  the  other 
along  the  gingival  wall.  This  should  then  be  forced  into  the 
substance  of  the  non-cohesive  gold  in  the  direction  of  the  gingivo- 
linguo-axial  angle,  so  as  to  incorporate  the  two  forms  of  gold  into 
one  mass.  After  pinning  this  pellet  of  cohesive  gold  into  the  non- 
cohesive  at  several  points  with  hand  pressure,  another  cylinder 
of  cohesive  gold  may  be  forced  into  the  gingivo-labio-axial  angle 
in  the  same  manner.  These  two  pellets  will  usually  reach  across 
the  entire  gingival  wall,  but  if  they  do  not  a  third  one  may  be 
used  to  connect  the  two.  When  there  is  a  complete  covering  of 
cohesive  gold  over  the  non-cohesive  the  mallet  may  be  used  for 
the  first  time,  and  the  entire  mass  malleted  to  place.  The  result 
is  that  the  gingival  wall  is  perfectly  protected  by  a  cushion  of  non- 
cohesive  gold  covered  by  a  layer  of  cohesive  gold,  and  the  whole 
locked  between  the  labial  and  lingual  walls  of  the  cavity  "with  a 
slight  excess  of  gold  overlying  the  gingival  enamel-margin  to  in- 
sure sufficient  material  for  a  perfect  finish. 

In  building  the  filling  from  this  point  the  pellets  of  cohesive  gold 
should  be  laid  with  their  sides  looking  toward  the  gingival  wall 
and  their  ends  looking  labially  and  lingually,  and  each  pellet 
should  be  wide  enough  to  reach  from  the  axial  wall  to  the  extreme 
proximal  surface  of  the  filling.  With  this  arrangement  of  the 
pellets  the  condensation  is  in  the  direction  of  the  long  axis  of  the 
tooth,  and  the  filling  is  kept  sufficiently  prominent  on  its  proximal 
surface  while  it  is  being  built  down  to  avoid  the  necessity  of  subse- 
quently adding  any  gold  laterally  to  this  surface  to  round  out  the 
filling.     Gold  tacked  on  the  proximal  surface  of  one  of  these 


188  PKINCIPtES    AND    PKACTICE    OF    FILLHSTG    TEETH. 

fillings  by  laying  the  pellet  on  its  side  and  directing  the  mallet 
force  at  right  angles  with  the  long  axis  of  the  tooth  is  not  so  se- 
curely maintained  in  place  as  it  is  where  the  arrangement  of  the 
gold  is  such  that  each  pellet  reaches  from  the  proximal  surface  to 
the  axial  wall  and  is  built  toward  the  gingival  wall.  The  operator 
cannot  always  avoid  the  necessity  of  arranging  his  gold  so  that 
the  condensation  is  in  the  direction  of  the  axial  wall,  but  this  neces- 
sity is  usually  confined  to  small  fillings  where  the  means  of  ap- 
proach will  not  permit  of  any  other  arrangement,  and  where  the 
element  of  strength  is  not  so  material. 

One  important  consideration  in  building  these  fillings  relates 
to  the  protection  of  the  lingual  margin.  This  seems  to  be  the 
most  difiicult  feature  in  their  insertion,  and  it  is  where  operators 
fail  more  often  than  at  any  other  point.  This  failure  is  usually 
due  to  inadequate  covering  of  the  margin  as  the  gold  is  being  built 
along  the  lingual  wall  toward  the  incisal  angle.  A  slight  excess 
of  gold  should  invariably  be  carried  over  this  margin,  and  in  order 
to  be  assured  of  this  the  operator  should  keep  the  gold  in  the 
lingual  region  built  somewhat  in  advance  of  the  filling  at  the 
labial  margin.  That  is,  the  gold  should  extend  farther  incisally 
along  the  lingual  than  along  the  labial  wall,  so  that  the  operator 
may  clearly  see  the  lingual  margin  and  thus  be  certain  of  lapping 
the  gold  over  it.  If  the  labial  part  of  the  filling  be  built  in  the 
least  advance  of  the  other,  it  obstructs  the  view  of  the  lingual 
margin  and  prevents  access  with  the  plugger. 

As  the  filling  is  being  built  down  toward  the  incisal  angle,  the 
operator  must  have  a  care  not  to  approach  too  near  the  angle  before 
wedging  some  gold  into  the  angle  and  between  it  and  the  filling 
already  in  place.  If  the  cavity  is  deep  pulpally,  so  as  to  leave  an 
appreciable  pocket  between  the  condensed  gold  and  the  incisal 
angle  of  the  cavity,  it  is  advisable  to  use  a  short  rope  of  non- 
cohesive  gold  to  wedge  into  this  pocket  to  be  assured  of  perfect 
adaptation.  Into  this  non-cohesive  gold  a  small  pellet  of  cohesive 
gold  may  be  forced  with  hand  pressure,  and  the  filling  completed 
with  the  mallet. 

When  a  filling  is  thus  inserted  it  will  be  found  that  there  is  a 


IXTKODLCTION    AND    FINISHING    OF    GOLD    FILLINGS.  181) 

slight  excess  of  gold  overlapping  the  margins  of  the  cavity,  and  the 
final  step  in  condensing  such  a  filling  should  be  to  mallet  down 
this  gold  with  a  foot  plugger.  If  access  cannot  be  gained  with  a 
plugger  a  very  thin  burnisher  may  be  used  to  force  the  gold  to 
place,  burnishing  from  the  center  of  the  filling  toward  and  over 
the  margins.      Then  the  filling  is  ready  for  polishing. 

In  cavities  where  the  lingual  wall  is  missing  and  the  labial  wall 
perfect,  so  that  the  filling  must  be  built  from  the  lingual  aspect, 
the  same  general  principles  of  filling  building  may  be  followed, 
except  that  the  gold  should  be  started  in  the  gingivo-labial  region 
instead  of  the  gingivo-lingual,  and  the  filling  kept  more  prominent 
along  the  labial  wall  as  it  approaches  the  incisal  angle.  The  same 
care  must  be  exercised  in  lapping  an  excess  of  gold  over  the  labial 
margin  while  the  filling  is  being  built  that  was  advised  for  the 
lingual  margin  while  building  from  the  labial  aspect.  It  is  well- 
nigh  impossible  to  tack  gold  on  the  labial  region  of  the  filling  after 
it  has  been  built  down  to  the  incisal  angle,  and  the  operator  should 
therefore  provide  perfect  protection  to  this  wall  while  he  has  the 
opportunity. 

In  those  cases  with  the  lingual  wall  missing  but  the  labial  aspect 
so  open  that  the  filling  must  be  built  mostly  from  this  direction, 
the  gold  should  be  started  in  the  regular  way,  and  as  the  lingual 
margin  is  being  covered  a  portion  of  each  pellet  should  be  allowed 
to  extend  some  distance  over  the  margin  and  hang  beyond  the 
lingual  surface  of  the  tooth.  This  end  of  the  pellet  cannot  be  con- 
densed from  the  labial  aspect,  but  the  portion  reaching  into  the 
cavity  can  be  made  fast  to  the  filling  and  the  filling  built  as  full 
as  convenient  from  this  aspect.  When  the  labio-proximal  portion 
of  the  filling  is  built  to  form  it  will  be  found  that  from  the  lingual 
aspect  a  large  mass  of  uncondensed  gold  extends  lingually  beyond 
the  margin,  each  pellet  of  which  is  securely  fastened  into  the 
substance  of  the  condensed  portion  of  the  filling.  This  uncon- 
densed mass  will  ordinarily  not  contain  sufficient  gold  to  properly 
round  out  the  filling  when  malleted  to  place  without  the  addition 
of  more  gold,  'and  it  is  the  addition  of  this  gold  from  the  lingual 
aspect  which  often  proves  troublesome  to  operators.     To  avoid 


190  PKINCIPLES    AND    PBACTICE    OF    FILLING    TEETH. 

difficulty  of  this  nature  it  is  suggested  to  take  an  annealed  pellet 
and  force  it  with  hand  pressure  up  into  the  structure  of  the  uncon- 
densed  gold  before  malleting  the  latter  to  place.  If  this  be  done 
the  freshly  annealed  pellet  will  leave  a  surface  to  which,  if  neces- 
sary, more  gold  may  be  attached  with  greater  certainty  than 
where  the  uncondensed  gold  has  been  malleted  without  this  pre- 
caution. 

The  object  of  leaving  this  excess  of  uncondensed  gold  is  to 
enable  the  operator  to  interweave  the  freshly  annealed  pellets  into 
its  substance,  and  thus  prevent  flaking  of  the  lingual  portion  of 
tlie  filling,  which  is  likely  to  occur  where  an  attempt  is  made  to 
condense  the  gold  as  the  filling  is  being  built  down,  and  then  add 
more  gold  to  the  condensed  surface  from  the  lingual  aspect. 
Wherever  possible  the  practice  should  be  avoided  of  leaving  for 
any  length  of  time  a  condensed  surface  of  gold  exposed  to  the 
atmosphere  with  the  expectation  of  subsequently  adding  more  gold 
to  it.  The  property  of  cohesion  seems  to  be  more  or  less  impaired 
by  exposure,  and  in  order  to  secure  the  best  working  quality  to 
cohesive  gold  it  will  be  found  desirable  to  add  pellet  after  pellet  to 
the  freshly  condensed  surfaces  from  beginning  to  completion  of 

the  operation. 

Pluggers. 

The  choice  of  pluggers  becomes  largely  a  matter  of  personal 
selection  with  most  operators,  but  for  these  proximal  fillings  in 
anterior  teeth  the  forms  here  illustrated  would  seem  to  answer  a 
convenient  purpose.  Fig.  84  is  suggested  for  starting  the  filling 
and  locking  the  gold  into  the  gingival  third  of  the  cavity.  ltd 
length  from  the  serrated  end  to  the  angle  is  sufficient  to  reach 
perfectly  to  the  gingival  region  of  any  cavity  on  an  incisor,  and  the 
degree  of  curve  is  such  that  direct  hand  pressure  or  mallet  force 
may  be  exerted  against  the  gingival  wall.  In  cavities  of  large 
area  with  ready  access  much  of  the  filling  may  be  built  with  it  to 
the  point  where  the  incisal  angle  requires  protection,  but  for 
small  cavities  other  forms  are  mostly  indicated. 

As  the  incisal  angle  is  reached  a  plugger  of  smaller  size,  and 
with  a  greater  curve,  is  required,  such  as  the  pair,  right  and  left, 


INTRODUCTIOX    AND    FINISHING    OF    GOLD    FILLINGS. 


191 


illustrated  in  Fig.  85.  Occasionally  even  these  forms  will  not 
properly  reach  the  angle  on  account  of  the  position  of  the  proxi- 
niating  tooth,  and  where  such  is  the  case  a  small,  short  right-angle 
plugger  is  indicated,  Fig.  86.  These  right-angle  pluggers  are 
invariably  to  be  used  with  hand  pressure,  and  in  cases  difficult  of 
access  the  gold  may  often  be  ^'tucked  up"  into  an  angle  in  this  way 
when  mallet  force  is  entirely  impracticable. 

For  building  fillings  from  the  lingual  aspect  in  all  cavities  of 
sufficient  size  Fig.  84  is  especially  adapted,  on  account  of  its 
adequate  reach.      In  caA^ties  too  limited  for  its  use,  whether  of 


Fig.  84. 


Fig.  85. 


Fig.  86.     Fig.   87.     Fig.  e 
o  tt  Bsa 


Fig.  89. 


labial  or  lingual  aspect,  the  form  illustrated  in  Fig.  87  may  be  sub- 
stituted to  advantage  in  conjunction  with  the  curved  pair  Fig.  85. 
One  important  factor  in  securing  the  most  stable  anchorage  of 
these  fillings  relates  to  perfect  density  of  the  gold  along  the  angles 
which  join  the  walls  of  the  cavity.  As  has  previously  been  stated, 
accurate  adaptation  of  gold  may  be  obtained  to  any  angle  provided 
the  proper  form  of  plugger  point  is  used,  and  for  this  purpose  such 
a  form  as  that  in  Fig.  88  is  excellent  in  those  positions  where  it 
will  approach.  Another  form  suggested  for  places  where  Fig.  88 
will  not  reach,  and  especially  for  curving  under  the  labial  wall  and 
carrying  the  gold  into  the  angle  between  the  labial  and  axial  walls, 
is  shown  in  Fig.  89.  In  cavities  where  these  forms  are  not  avail- 
able for  the  angles  the  curved  pluggers  with  round  points  may  be 


192  PRI2STCIPLES    AND    PRACTICE    OF    FILLIIS'G    TEETH. 

made  to  do  good  service,  and  secure  perfect  adaptation  by  exercis- 
ing care  and  malleting  step  by  step  along  tlie  angle  so  that  the 
plugger  point  covers  the  entire  mass  of  gold  with  the  mallet  im- 
pact. For  the  surface  of  these  fillings,  according  to  their  area,, 
pluggers  ranging  from  Fig.  88  up  to  a  small-sized  foot  plugger 
may  be  used  to  give  an  even,  dense  surface. 

Finishing  Proximal  Fillings  in  Incisors. 

When  the  filling  is  built  to  proper  form  the  gold  will  ordinarily 
be  found  to  knuckle  tightly  against  the  contact  point  of  the  proxi- 
mating  tooth,  and  in  finishing  the  filling  the  operator  must  avoid 
cutting  away  the  gold  at  this  point,  and  thus  producing  a  flat 
proximal  surface  to  the  filling.  The  gold  should  be  left  rounded 
out  to  a  contact  point,  the  same  as  was  on  the  tooth  originally 
before  decay  began.  To  this  end  a  narrow  finishing  strip  should 
be  used  in  the  interproximal  space  to  dress  the  gingival  third  of  the 
filling  to  form,  and  this  part  of  the  filling  should  be  finished  even 
Avith  the  surface  of  the  tooth  before  any  attempt  is  made  to  trim 
the  filling  at  other  points.  The  strip  should  not  be  so  wide  that  in 
drawing  it  back  and  forth  between  the  teeth  it  will  reach  to  the 
contact  point  and  cut  it  down..  If  the  filling  is  so  snug  against  the 
proximating  tooth  that  the  strip  cannot  be  carried  between  the 
teeth,  it  may  be  introduced  endwise  into  the  interproximal  space 
from  the  labial  aspect. 

When  the  gingival  margin  is  properly  trimmed  to  form,  the 
gingivo-lingual  portion  of  the  filling  may  often  be  dressed  down  by 
carrying  the  cutting  surface  of  the  strip — which  is  still  in  the  inter- 
proximal space — as  nearly  as  possible  along  the  lingual  surface  of 
the  tooth,  and  the  back  or  smooth  side  of  the  strip  across  the  labial 
surface  of  the  proximating  tooth.  This  brings  pressure  of  the 
cutting  side  of  the  strip  to  bear  immediately  on  the  gingivo-lingual 
part  of  the  filling,  and  it  does  not  cut  at  any  other  point. 

After  the  narrow  strip  has  been  used  it  will  often  be  found  con- 
venient to  slip  on  a  separator  where  one  has  not  previously  been 
employed,  and  force  the  teeth  slightly  apart  to  admit  of  a  finishing 
strip  being  carried  between  the  teeth.     Where  this  cannot  be  done 


IXTRODUCTION    AND    FINISHING    OF    GOLD    FILLINGS.  193 

a  very  thin,  broad  burnisher,  battered  out  to  a  uniform  thickness 
and  having  a  sharp  edge,  after  the  nature  of  the  Dunn  hand  matrix, 
should  be  forced  between  the  filling  and  the  proximating  tooth, 
and  the  end  of  the  handle  swung  back  and  forth,  describing  the 
arc  of  a  circle,  while  the  blade  is  held  between  the  teeth  till  there  is 
more  or  less  freedom  of  movement  of  the  burnisher.  This  will 
ordinarily  smooth  the  gold  so  that  a  strip  may  be  passed  between 
the  teeth. 

The  strip  used  for  finishing  this  portion  of  the  filling  should  be 
broad,  and  in  manipulating  it  the  cutting  surface  should  be  drawn 
quite  sharply  across  the  labial  and  lingual  surfaces  of  the  tooth,  so 
that  the  filling  will  be  rounded  and  the  labial  and  lingual  aspects 
dressed  even  with  the  cavity-margins.  In  those  cases  where  the 
lingual  surface  of  the  tooth  is  so  concave  that  the  strips  will  not 
follow  the  outline  of  the  cavity,  a  sand-paper  disk  in  the  engine 
may  be  used  to  dress  this  portion  of  the  filling  to  form  by  directing 
the  disk  into  the  concavity  with  a  round-headed  burnisher. 

After  the  filling  is  of  the  proper  form  it  may  be  polished  with  a 
finishing  strip  of  the  finest  grit,  or  thin  linen  tape  may  be  used, 
carrying  with  it  fine  pumice,  followed  by  whiting.  All  of  this 
should  be  done  before  the  removal  of  the  rubber  dam,  on  account 
of  the  protection  afforded  by  the  dam  to  the  gums  and  lips,  and 
also  because  the  saliva  interferes  with  the  work. 

Whenever  strips  or  disks  are  used  in  finishing  gold  fillings  they 
should  invariably  be  smeared  with  vaseline,  oil,  or  some  similar 
lubricant  to  avoid  as  much  as  may  be  the  generation  of  heat  in  the 
filling.  The  lubricant  also  renders  the  disk  pliable,  and  it  can 
therefore  be  directed  into  depressions  with  a  round-headed  instru- 
ment— such  as  a  ball  burnisher — to  much  better  advantage  than 
where  such  an  attempt  is  made  with  a  dry  disk.  This  practice  will 
also  prove  of  considerable  financial  advantage  to  the  dentist  if  ho 
will  preserve  his  worn-out  disks  and  strips  and  send  them  to  the 
refiner.  The  amount  of  gold  retained  on  the  sanded  surface,  if 
lubricated  this  way,  will  in  the  aggregate  yield  a  surprising  profit 
in  the  course  of  a  year,  and  no  operator  should  ignore  this  kind  of 
economy. 

13 


194  PEINCIPLES    AND    PKACTICE    OF    FILLING    TEETH. 

Anotlier  aid  in  the  maintenance  of  a  normal  temperature  in  a 
filling  under  the  friction  of  a  strip  or  disk  may  be  made  available 
by  those  who  have  compressed  air  at  their  command.  If  a  jet  of 
air  be  allowed  to  play  upon  the  filling  during  the  process  of  polish- 
ing, it  will  be  found  to  equalize  the  temperature  and  render  the 
^vork  more  tolerable  to  the  patient. 

Proximal  Fillings  in  Anterior  Teeth  involving  the  Incisal  Angle. 

The  method  of  building  these  fillings  is  practically  the  same  as 
that  for  simple  proximal  fillings  down  to  the  point  where  the 
incisal  anchorage  is  made,  except  that  in  the  contour  fillings  the 
open  aspect  of  the  cavity  renders  it  possible  to  more  uniformly  lay 
the  gold  on  parallel  with  the  gingival  wall  and  at  right  angles  to 
the  stress  of  mastication.,  In  these  large  fillings  the  proximal  sur- 
face should  be  kept  suflSciently  prominent  as  the  filling  is  being 
built  from  the  gingival  to  the  incisal  region,  to  make  it  unnecessary 
to  add  more  gold  laterally  to  the  proximal  surface  to  complete 
its  contour. 

In  those  cases  where  the  incisal  anchorage  has  been  made  be- 
tween the  two  j)lates  of  enamel  in  the  incisal  third  of  the  axial  wall, 
the  greatest  care  must  be  exercised  in  securing  perfect  adaptation 
and  density  of  the  gold  in  this  anchorage.  Small  pieces  of  gold 
must  be  used,  and  each  piece  compactly  malleted  to  place  with 
small  pluggers.  The  slightest  lack  of  density  or  the  slightest 
bridging  of  the  gold  at  this  point  must  eventually  result  in  a  spring- 
ing away  of  the  incisal  portion  of  the  filling  which  sooner  or  later 
leads  to  its  loss. 

Where  the  incisal  anchorage  is  made  by  cutting  a  step  or  groove 
across  the  end  of  the  tooth  at  right  angles  to  the  proximal  cavity, 
as  suggested  in  considering  cavity  preparation,  the  method  of  build- 
ing the  filling  is  to  carry  the  gold  down  the  proximal  portion  of 
the  cavity  level  mth  the  base  of  the  step  in  the  ordinary  way,  and 
theu  lay  a  pellet  with  its  side  presented  to  the  floor  of  the  step  and 
its  ends  looking  mesially  and  distally,  reaching  from  the  center  of 
the  gold  already  condensed  over  into  the  step.  The  pellet  should 
be  fastened  securely  to  the  condensed  gold,  and  then  malleted  to 


IXTEODUCTIOX    A^'D    FINISHIXG    OF    GOLD    FILLIIS'GS.  195 

place  in  the  step.  Another  pellet  should  be  laid  slightly  farther 
along  the  step,  but  with  one  end  still  lapping  the  gold  already  in 
place.  In  this  way  the  proximal  portion  of  the  filling  is  seciirely 
locked  into  the  step,  and  the  greatest  possible  strength  is  given  the 
gold  at  the  point  where  the  proximal  joins  the  incisal  portion  of 
the  filling  by  such  an  arrangement  of  the  pellets.  This  process  of 
building  the  gold  should  be  carried  on  till  the  end  of  the  step  ia 
reached.  The  entire  incisal  portion  of  the  filling  must  be  built  up 
with  the  greatest  care,  and  the  arrangement  of  the  pellets,  so  far  as 
possible,  should  be  in  the  order  already  suggested, — the  sides  at 
right  angles  to  the  force  of  occlusion,  and  the  ends  looking  mesially 
and  distally  across  the  step. 

The  gold  should  be  perfectly  annealed  and  small  pellets  em- 
ployed, to  the  end  that  the  greatest  degree  of  density  and  resisting 
power  is  imparted  to  the  gold.  For  this  portion  of  the  filling  it  is 
sometimes  desirable  to  use  the  hea\der  golds  in  strips,  such  as  the 
Xo.  60  rolled  gold;  or  in  cases  where  extreme  density  is  desired 
platinum  and  gold  may  be  employed.  If  the  rolled  gold  is  used  it 
should  not  be  added  till  the  surface  is  nearly  reached,  on  account  of 
the  greater  difiiculty  of  securing  perfect  adaptation  to  the  labial 
plate  of  enamel. 

This  is  one  of  the  most  important  considerations  in  building  these 
fillings.  Unless  the  gold  is  adapted  to  the  labial  plate  with  the 
greatest  accuracy  there  will  eventually  occur  a  leak  at  this  point, 
which  will  result  in  such  discoloration  as  to  make  the  tooth  un- 
sightly. The  angle  between  the  labial  plate  and  the  step  should 
also  receive  close  attention  in  adapting  the  gold,  so  that  the  filling 
may  be  securely  seated  in  place. 

For  building  this  portion  of  the  filling  pluggers  88  and  89  are 
admirably  adapted,  though  larger  sizes  may  be  used  in  cases  where 
the  area  of  the  cavity  will  permit  it.  In  teeth  long  and  thin,  wdiere 
the  step  must  be  correspondingly  deep  and  narrow  and  where  it 
has  been  made  to  terminate  in  a  depression,  for  the  more  secure 
anchorage  of  the  filling  a  plugger  as  small  as  Fig.  87  may  be 
rcfpiired  to  reach  the  deepest  part  of  the  step  and  bring  this  por- 
tion of  tlu'  filling  level  with  the  rest;  but  when  this  is  accomplished 


196  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

Pigs.  88  and  89  will  ordinarily  be  found  none  too  large  to  com- 
plete the  operation.  As  the  surface  of  the  filling  is  reached  the 
gold  should  be  malleted  somewhat  beyond  the  stage  where  it  seems 
dense,  on  the  theory  that  repeated  blows  harden  gold  and  make  it 
more  resistant,  even  after  compactness  has  been  reached.  In  going 
over  the  surface  for  the  last  time  with  the  mallet  a  smooth-faced 
plugger  may  be  used,  and  the  blows  so  arranged  that  the  final  ones 
are  invariably  struck  along  the  margins. 

For  finishing  the  incisal  aspect  of  these  fillings  a  sand-paper  disk, 
held  to  position  with  a  ball  burnisher,  will  quickly  dress  the  filling 
to  form,  after  which  it  may  be  polished  with  a  fine  cuttle-fish  disk. 

Fillings  in  Proximo-Occlusal  Cavities  in  Bicuspids  and  Molars. 

The  Matrix. — A  necessary  concomitant  to  the  proper  considera- 
tion of  the  insertion  of  contour  fillings  in  bicuspids  and  molars 
relates  to  the  question  of  the  matrix.  A  perfect  understanding  of 
its  advantages  and  limitations  should  be  acquired  by  every  opera- 
tor, in  view  of  the  fact  that  if  properly  employed  under  suitable 
conditions  it  is  capable  of  materially  lessening  the  fatigue  and 
difficulty  of  these  operations,  while  if  used  ill-advisedly  or  un- 
skillfuUy  it  leads  to  the  gravest  defects  in  the  work  and  proves 
simply  a  delusion  and  a  snare. 

The  chief  office  of  the  matrix  is  to  supply  the  missing  wall  of  a 
cavity,  thus  converting  a  proximal  cavity  of  three  walls  into  one 
of  surrounding  walls.  This  becomes  a  matter  of  very  great  im- 
portance in  distal  cavities  far  back  in  the  mouth,  on  account  of 
the  angle  at  which  a  plugger  must  approach  such  cavities.  Unless 
there  is  a  supporting  matrix-wall  against  which  to  build  the  gold, 
the  filling  must  either  be  made  unnecessarily  full  while  it  is  being- 
built  or  else  it  must  fail  of  adequate  density  on  the  proximal  sur- 
face. With  a  matrix  properly  adjusted,  the  correct  contour  can 
readily  be  given  the  filling  while  the  gold  is  being  condensed, 
so  that  little  trimming  is  necessary  in  finishing,  and  the  surface 
may  be  made  as  hard  as  desired.  It  will  very  materially  lessen 
the  labor  and  nervous  strain  of  an  operation,  and  will  therefore 
well  repay  the  study  necessary  for  its  successful  use. 


INTRODUCTIOX    AXD    FIXISHIXG    OF    (iOLD    FILLIXGS.  197 

The  main  objections  urged  against  the  matrix  may  be  summar- 
ized as  follows:  The  difficulty  of  obtaining  adaptation  of  the  gold 
into  the  angle  formed  by  the  junction  of  the  matrix  with  the  mar- 
gin of  the  cavity  thus  resulting  in  imperfect  margins  to  the  filling, 
and  the  obstruction  which  the  matrix  is  supposed  to  form  to  a 
good  view  of  the  cavity.  Each  of  these  objections  is  well  founded 
under  certain  conditions,  and  each  is  equally  inoperative  under 
certain  other  conditions.  If  a  thick,  stiff  matrix  is  used  and 
tightly  wedged  against  the  cavity  outline,  it  will  be  found  difficult 
to  properly  carry  the  gold  over  the  enamel-margin  and  secure  a 
perfect  sealing  of  the  cavity,  but  if  a  matrix  is  made  of  a  thin, 
springy  material,  capable  of  being  forced  away  from  the  cavity* 
margin  at  will,  so  that  the  gold  may  be  carried  between  the 
matrix  and  the  margin,  there  is  really"  no  obstacle  in  the  way  of 
doing  perfect  work.  In  fact,  the  proper  use  of  the  matrix  will  fa- 
cilitate the  making  of  good,  dense  margins  to  our  fillings  with  less 
difficulty  in  these  distal  cavities  than  where  the  attempt  is  made  to 
build  the  filling  in  an  open  cavity.  The  matrix  is  a  support  to  the 
gold  during  condensation,  and  it  has  a  sustaining  influence  to  hold 
the  filling  to  form  under  the  impact  of  the  plugger.  If  a  mallet 
blow  is  used  on  the  gold  in  the  direction  in  which  it  is  often  neces- 
sary in  these  cavities  far  back  in  the  mouth,  the  tendency  is  to  force 
the  gold  away  from  the  cavity-margins,  unless  there  is  some  sus- 
taining wall  against  which  to  build.  This  matrix-wall  keeps  the 
gold  up  to  its  place  and  gives  the  opportunity  for  free  malleting 
without  rolling  the  gold  away  from  the  axial  wall  and  margins. 

This  does  not  imply  that  the  greatest  care  is  not  always  neces- 
sary in  the  use  of  the  matrix.  As  has  been  intimated,  no  matrix 
should  be  used  which  is  not  capable  of  being  forced  by  the  plugger 
sufficiently  away  from  the  cavity  to  admit  a  mat  of  gold  between  it 
and  the  margin.  Given  a  matrix  which  on  adjustment  fits  ap- 
proximately to  the  margins  of  the  cavity,  the  aim  should  be,  in 
placing  the  first  pieces  of  gold  over  the  gingival  wall,  to  so  force 
back  the  matrix  with  the  plugger  that  it  Avill  stand  away  from  the 
buccal  and  lingual  margins  at  least  half  a  niillimeter,  and  this 
space  sbouhl  Ije  iiuiintiiiiicd  tlirongliont  the  building  of  the  filling. 


198  PEINCIPLES    AND    PEACTICE    OV    FILLING    TEETH. 

If  this  is  done  the  margins  may  be  readily  covered  and  the  gold 
made  dense  and  perfectly  adapted. 

The  objection  as  to  the  obstruction  of  light  and  vision  from  the 
cavity  holds  good  if  a  broad  matrix  be  used  on  a  mesial  cavity,  but 
there  is  no  obstruction  whatever  on  a  distal  cavity.  In  view  of  the 
fact  that  there  is  seldom  any  necessity  for  a  broad  matrix  on  a 
mesial  cavity,  the  question  becomes  one  of  judgment  in  the  selec- 
tion of  suitable  cases  for  the  matrix  rather  than  one  bearing  on  a 
fundamental  objection  to  the  appliance  itself.  The  most  that  is 
ever  required  in  the  way  of  a  matrix  on  a  mesial  cavity  is  a  narrow 
strip  of  metal  placed  across  the  gingival  third  of  the  cavity  to  give 
form  to  the  filling  in  the  interproximal  space  and  provide  a  guid- 
ing wall  against  which  the  filling  may  be  so  built  that  it  will 
require  very  little  subsequent  trimming  in  finishing  it.  This  does 
not  materially  obstruct  the  view  of  the  cavity,  and  it  furnishes  all 
that  is  necessary  in  the  way  of  a  matrix  for  these  cavities. 

Another  objection  which  is  sometimes  urged  against  the  matrix 
may  be  mentioned  merely  to  controvert  it,^ — viz,  the  difficulty  of 
securing  adaptation  of  gold  to  the  surface  of  the  matrix.  The 
claim  is  made  that  in  building  gold  against  a  matrix  it  is  seldom 
that  a  filling  is  perfect  on  the  proximal  surface  owing  to  spaces 
being  left  here  and  there  as  the  gold  is  laid  against  the  matrix. 
If  this  be  true,  it  is  due  to  either  one  of  two  things, — an  oversight 
on  the  part  of  the  operator  or  improperly  formed  pluggers.  That 
gold  can  be  perfectly  adapted  to  a  surface  like  the  matrix  has  been 
too  often  demonstrated  to  require  further  emphasis.  It  is  surely  as 
easy  to  adapt  gold  to  a  matrix  as  to  the  wall  of  a  cavity,  and  it  is 
safe  to  conclude  that  in  many  of  the  cases  where  the  surface  of  the 
filling  next  to  the  matrix  has  been  found  defective  the  surfaces  next 
to  the  walls  of  the  cavity  would  present  similar  imperfections,  if 
the  same  facilities  for  examination  were  available.  The  chief  dis- 
tinction between  building  gold  against  the  flat  surface  of  a  matrix 
and  the  flat  surface  of  a  cavity  is  that  the  former  is  somewhat  more 
disastrous  to  plugger  points  than  the  latter,  the  serrations  being 
more  rapidly  battered  down  when  coming  in  contact  with  steel  than 
with  dentine  or  enamel. 


IXTEODUCTIOX    A^'D    FINISHING    OF    GOLD    FILLINGS. 


199 


The  Kind  of  M<ifi-ix. — Xo  one  form  of  matrix  may  be  deemed 
available  for  all  cases,  and  in  some  instances  it  will  be  found  desir- 
able to  improWse  a  matrix  specially  for  the  case  in  hand.  The 
band  matrices  made  of  thin  steel,  such  as  the  Brophy  matrix  (Fig. 
90),  serve  an  excellent  purpose  for  ordinary  work,  though  they  are 
not  universally  applicable.  The  material  of  which  these  matrices 
are  made  is  almost  ideal  for  the  purpose.  The  steel  is  sufficiently 
rigid  to  sustain  the  gold  against  thorough  malleting,  and  yet  its 
springy  nature  admits  of  it  being  forced  away  from  the  cavity- 
margins  by  pressure  of  the  plugger.  There  are  some  objections  to 
these  matrices  which  occasionally  assert  themselves,  chief  of  which 
may  be  mentioned  the  fact  that  in  bell-crowned  teeth  the  matrix 

Fig.  90. 


embraces  the  tooth  tightly  near  the  occlusal  surface  and  stands 
some  distance  away  from  the  neck  along  the  gingival  half  of  the 
cavity.  This  objection  may  readily  be  overcome  by  packing  some 
gutta-percha  into  the  interproximal  space  between  the  matrix  and 
the  proximating  tooth,  so  as  to  force  the  matrix  up  to  the  gingival 
margin  of  the  cavity.  Wooden  wedges  have  sometimes  been  advo- 
cated for  this  purpose,  but  the  danger  with  these  is  that  the  wedge 
is  likely  to  force  the  matrix  too  close  to  the  margin,  and  the  wood 
is  so  unyielding  that  the  plugger  cannot  press  the  matrix  back  to 
allow  the  gold  between  it  and  the  margin.  With  gutta-percha  the 
matrix  may  be  carried  as  close  to  the  cavity  as  desired,  and  the 
material  will  be  found  sufficiently  yielding  to  admit  of  manipula- 
tion by  the  plugger  .so  as  to  .secure  perfect  protection  to  the  cavity- 
margins. 

Another  difficnltv  sometimes  encountered  with  the  band  nuitrix 


200  PKINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

is  the  problem  of  maintaining  it  in  position  on  teeth  that  are  more 
cone-shaped  than  bell-crowned, — where  the  axial  surfaces  slope 
from  the  gingival  line  to  the  occlusal  surface  in  such  a  way  as  to 
present  an  inclined  plane  along  which  the  matrix  slides  to  its  dis- 
placement. Occasionally  this  may  be  prevented  by  packing  hot 
gutta-percha  between  the  matrix  and  the  buccal  and  lingual  sur- 
faces of  the  teeth  and  letting  it  cool  before  there  is  any  manipula- 
tion of  the  matrix.  If  the  gutta-percha  is  quite  hot,  it  will  be  more 
or  less  adhesive  both  to  the  matrix  and  the  enamel,  and  it  will 
often  prove  effective.  In  cases  where  this  will  not  answer  cement 
may  be  substituted,  though  this  requires  so  much  time  for  its  appli- 
cation and  crystallization  that  it  is  indicated  only  in  those  cases 
where  nothing  else  will  suffice  and  where  such  a  matrix  seems  to 
be  especially  demanded. 

Another  feature  of  the  band  matrix  calls  for  attention  so  far  as 
the  comfort  of  the  patient  is  concerned.  In  very  many  of  the 
cases  where  a  matrix  is  indicated  it  will  be  found  that  the  decay 
has  extended  so  far  rootwise  that  the  gingival  margin  of  the  cavity 
is  some  distance  beyond  the  original  free  margin  of  the  gum. 
This  tissue  has  consequently  either  receded  or  been  forced  out  of 
the  way  with  gutta-percha  in  the  manner  already  described  in  the 
consideration  of  cavity  preparation.  Under  these  conditions  the 
gum  in  the  adjoining  interproximal  spaces  extends  much  farther 
crownwise  than  that  in  the  affected  space,  and  if  the  matrix  is 
carried  sufficiently  rootwise  to  cover  the  gingival  margin  of  the 
cavity, — ^which  it  must  be  in  order  to  prove  effective, — that  portion 
of  the  band  in  the  adjoining  interproximal  space  impinges  forcibly 
on  the  gum-tissue,  to  the  serious  discomfort  of  the  patient.  The 
only  remedy  for  this  is  to  cut  away  the  edge  of  the  band  which 
passes  into  the  adjoining  space  in  such  a  manner  that  a  considerable 
concavity  is  presented  to  the  gum  instead  of  a  convexity,  and  this 
should  be  done  with  all  band  matrices,  even  though  it  involves 
the  necessity  of  having  a  separate  set  for  each  side  of  the  mouth. 

When  it  becomes  desirable  to  make  a  matrix  for  the  special  case 
in  hand,  a  suitable  material  for  the  purpose  is  found  in  copper  or 
German  silver  rolled  thin.     This  may  be  wrapped  around  the 


INTRODUCTION    AND    FINISHING    OF    GOLD    FILLINGS.  201 

tooth  and  fashioned  with  a  burnisher  to  any  desired  form,  and  the 
two  ends  tacked  together  with  solder. 

The  narrow  matrix  for  the  interproximal  space  in  the  manage- 
ment of  mesial  cavities  may  be  conveniently  made  from  an  old 
v.atch-spring.  This  should  be  broken  into  lengths  varying  from  a 
third  to  half  an  inch  for  the  different  sized  teeth,  and  then  ground 
convex  on  one  edge  so  as  to  dip  down  into  the  space  with  the  con- 
vexity looking  rootwise.  The  varying  degrees  of  curve  to  the 
spring  may  be  utilized  in  the  selection  of  suitable  forms  for  the 
different  teeth.  For  instance,  a  lower  second  bicuspid  which  is 
nearly  round  at  the  neck  would  call  for  a  matrix  made  from  near 
the  center  of  the  spring,  where  the  curvature  is  greatest,  while  for 
a  molar  with  a  broad  proximal  surface  the  matrix  should  be  made 
from  the  periphery  of  the  spring,  where  there  is  little  curve. 
These  matrices  may  be  slipped  between  the  teeth  and  held  in  place 
ordinarily  by  their  own  form,  the  convexity  of  the  curve  resting 
against  the  proximating  tooth  just  rootwise  of  the  contact  point. 
If  the  space  between  the  teeth  is  so  great  that  they  will  not  remain 
of  their  own  accord,  they  may  be  fastened  with  gutta-percha,  as 
already  described.  AVhen  the  filling  is  completed,  this  form  of 
matrix  should  be  removed  by  forcing  it  either  buccally  or  lin- 
gually,  it  being  ordinarily  impossible  to  remove  it  occlusally. 

Manner  of  Using  a  Matrix. — The  greatest  care  should  be  exer- 
cised in  securing  a  proper  adjustment  of  the  matrix  to  the  end 
that  it  shall  be  maintained  in  position  during  the  condensation  of 
the  gold,  and  that  it  shall  have  such  a  form  that  when  the  filling  is 
l»uilt  against  it  the  proximal  surface  of  the  filling  will  present  a 
contour  that  requires  little  trimming.  The  matrix  should  dip  in 
close  to  the  tooth  at  the  gingival  region  of  the  cavity,  and  stand  out 
tight  against  the  contact  point  of  the  proximating  tooth  near  the 
occlusal  surface.  If  it  does  not  take  this  position  when  applied  to 
the  tooth,  it  should  be  forced  to  take  it  by  packing  gutta-percha  in 
the  interproximal  space,  as  previously  suggested,  and  by  burnish- 
ing the  free  end  of  the  matrix  against  the  proximating  tooth. 
One  of  the  prime  advantages  of  the  matrix  is  that  by  its  use  a  fill- 
ing may  be  so  malleted  as  it  approaches  the  contact  point  of  the 


202  PRINCIPLES    AXD    PKACTICE    OF    FILLING    TEETH. 

IDroximating  tooth  tliat  the  contact  point  on  the  filling  is  given 
the  greatest  possible  density  without  building  any  excess  of  mate- 
rial. The  matrix  should  be  so  thin  that  when  the  filling  is  con- 
densed and  the  matrix  removed  there  is  practically  no  space  left 
and  the  gold  falls  against  the  proximating  tooth.  By  the  use 
of  the  matrix  a  tooth  may  be  filled  and  the  proper  contour  main- 
tained with  less  separating  than  where  no  matrix  is  used. 

Before  placing  any  gold  in  the  cavity  it  is  well  to  go  along  the 
matrix-wall  with  a  plugger  and  test  it,  to  see  if  it  may  be  pressed 
away  from  the  cavity-margins  at  will.  If  there  is  any  point  where 
it  seems  too  rigid,  so  that  there  is  likelihood  of  an  oversight  in 
adapting  the  gold,  this  portion  of  the  matrix  should  be  forced  away 
from  the  margin  in  advance  of  the  operation,  to  make  certain  of 
a  ready  overlapping  of  the  gold. 

When  the  matrix  is  satisfactorily  adjusted,  the  filling  may  be 
started  by  introducing  a  rope  of  non-cohesive  gold  along  the  gingi- 
val wall  and  wedging  it  into  the  angle  between  the  gingival  and 
axial  walls,  and  also  locking  it  into  the  gingivo-buccal  and  gingivo- 
lingual  angles.  When  the  first  part  of  the  filling  is  thus  securely 
fastened  in  position,  the  gold  should  be  carefully  condensed  over 
the  gingival  border  of  the  cavity  by  forcing  the  matrix  slightly 
away  from  the  margin  with  the  plugger  and  slipping  the  gold  in 
between  the  margin  and  the  matrix.  This  may  readily  be  done 
with  a  plugger  formed  like  that  in  Fig.  84,  placing  the  serrated  end 
on  the  gold  and  tipping  the  shank  against  the  matrix  to  force  it 
back.  When  this  is  successfully  accomplished  along  the  entire 
gingival  margin,  and  the  non-cohesive  gold  is  covered  by  a  layer 
of  cohesive  pellets,  the  mallet  may  be  used  to  secure  thorough  con- 
densation over  the  whole  area  of  gold,  and  especially  at  the  junc- 
tion of  the  gold  with  the  matrix.  The  plugger  should  be  carried 
step  by  step  along  the  matrix-wall  until  the  filling  is  hard  and 
dense.  If  this  precaution  is  taken  throughout  the  operation,  and 
if  the  gold  is  not  laid  on  in  too  large  masses,  there  will  be  no  doubt 
about  the  uniformity  of  density  on  the  proximal  surface  of  the 
filling. 

To  secure  the  best  results  in  building  against  a  matrix,  the 


IXTRODUCTIOX    AXD    FINISHIXG    OF    GOLD    FILLINGS.  -03 

pellets  should  be  laid  with  their  sides  to  the  matrix  and  their  ends 
looking  hiiecally  and  linguallj,  while  the  filling  shonld  be  kept 
nearly  horizontal. 

As  has  already  been  intimated,  from  the  time  the  first  pieces  of 
gold  have  been  forced  between  the  matrix  and  enamel  the  appli- 
ance shonld  be  kept  sufficiently  away  from  the  cavity  dur- 
ing the  operation  to  admit  of  carrying  the  gold  well  over  ^^°-  ^^^• 
the  peripheral  enamel-margin.  (Fig.  91.)  With  these 
precautions  there  is  no  need  for  poor  work  with  the  matrix, 
but  unless  an  operator  is  prepared  to  give  close  attention 
to  the  i')oints  indicated  he  would  better  dispense  with  the 
aj)pliance  altogether.  It  is  an  appliance  which  if  abused 
cr  misunderstood  is  exceedingly  treacherous,  and  will  result  in 
very  faulty  work,  but  if  used  wath  judgment  and  care  it  is  capa- 
ble of  materially  lessening  the  strain  of  these  complicated  opera- 
tions, and  will  prove  a  source  of  great  satisfaction  to  the  operator. 

The  plan  of  l)uilding  these  occluso-proximal  fillings  will  be  con- 
sidered in  greater  detail  under  the  heads  of  the  diiferent  cavities. 

Disto-Occlusal  Fillings  in  Left  Lower  Bicuspids  and  Molars. 

With  the  matrix  in  place  a  rope  of  non-cohesive  gold  of  suitable 
size  should  be  grasped  with  the  pliers  and  one  end  carried  into  the 
gingivo-lingual  angle,  and  the  rope  folded  on  itself  at  convenient 
inteiwals  along  the  gingival  wall  toward  the  buccal  wall.  If  the 
rope  is  not  of  sufficient  length  to  reach  entirely  to  the  buccal  wall 
when  thus  folded,  another  rope  should  be  started  in  the  gingivo- 
buccal  angle  in  the  same  way  and  the  two  ropes  joined.  With  a 
mass  of  non-cohesive  gold  thus  laid  along  the  gingival  wall,  the 
condensation  should  begin  by  taking  a  square-faced  plugger  wath 
a  serrated  area  as  broad  as  the  width  of  the  gingival  wall  mesio- 
distally,  and  bringing  it  down  on  the  gold  with  hand  pressure 
toward  the  gingivo-lingual  angle.  A  plugger  of  this  size  will 
carry  the  gold  ahead  of  it  instead  of  puncturing  it,  as  would  be  the 
case  with  one  of  too  limited  area;  and  if  operated  in  the  swaying 
motion  already  describe<l  it  will  insure  perfect  adaptation  of  the 
gold  without  the  rope  following  the  plugger  out  of  the  cavity. 
AVhen  the  plugger  has  l)een  brought  to  bear  on  the  non-cohesive 


204  PKINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

gold  at  several  points  along  the  gingival  wall,  so  as  to  compress  the 
gold  partially  into  position,  a  cylinder  of  cohesive  gold  wide 
enough  in  diameter  to  reach  from  the  axial  wall  to  the  gingival 
enamel-margin  should  be  laid  in  the  gingivo-lingual  angle  with  its 
side  upon  the  gold  already  in  place  and  one  end  looking  along  the 
gingival  wall,  while  the  other  is  slightly  tipped  up  against  the  lin- 
gual wall  and  looks  along  this  wall.  This  should  be  forcibly 
driven  into  the  structure  of  the  non-cohesive  gold  in  the  direction 
of  the  gingivo-linguo-axial  angle  by  hand  pressure  with  a  smaller 
plugger  exerted  in  the  swaying  motion,  and  when  securely  pinned 
into  place,  by  bringing  the  plugger  to  bear  on  it  at  several  points  in 
this  manner,  another  cylinder  may  be  laid  a  little  farther  along  the 
gingival  wall  toward  the  buccal  wall,  but  still  lapping  the  cohesive 
cylinder  already  in  place.  This  process  should  be  continued  with 
hand  pressure  till  the  cohesive  gold  reaches  across  the  gingival  wall 
to  the  buccal  wall,  and  especial  care  should  be  taken  to  force  the 
last  cylinder  so  placed  securely  into  the  gingivo-buccal  angle. 
When  the  filling  is  thus  locked  in  position  the  mallet  may  be  used 
to  condense  the  entire  mass,  starting  the  plugger  at  either  the 
gingivo-linguo-axial  angle  or  the  gingivo-bucco-axial  angle,  as  the 
case  indicates,  and  carrying  it  step  by  step  across  the  cavity,  direct- 
ing it  first  along  the  gingivo-axial  angle.  The  object  is  to  secure 
the  greatest  degree  of  adaptation  and  density  in  this  angle,  to  the 
end  that  the  filling  may  be  so  seated  in  position  that  there  is  no  pos- 
sibility of  subsequent  movement  from  manipulation.  A  con- 
venient form  of  plugger  for  this  purpose  is  found  in  Fig.  84. 

After  density  is  gained  along  the  gingivo-axial  angle  a  broader 
faced  plugger  may  be  used  to  condense  the  remaining  gold,  pro- 
vided the  area  of  the  gingival  wall  is  great  enough  to  call  for  it. 
Usually  in  bicuspids  the  width  of  the  gingival  wall  mesio-distally 
is  so  limited  that  the  form  Fig.  84  is  as  large  as  can  well  be  used. 

When  the  gold  is  thus  malleted  down  upon  the  gingival  wall  the 
plugger  should  be  directed  into  the  angle  formed  by  the  junction 
of  the  matrix  with  the  margin  of  the  cavity,  and  the  gold  should  be 
carried  against  the  matrix  and  over  the  entire  gingival  margin. 
This  will  force  the  matrix  slightly  away  from  the  margin  as  pre- 


IXTRODUCTIOX    AXD    FIXISHING    OF    GOLD    FILLIXGS.  205 

vioiisly  advised,  and  insure  perfect  adaptation  of  gold  over  the 
enamel. 

The  operation  now  presents  \\dth  the  gingival  portion  of  the  fill- 
ing in  place,  a  cushion  of  non-cohesive  gold  lying  against  the 
gingival  wall  with  a  layer  of  thoroughly  condensed  cohesive  gold 
covering  it,  and  the  whole  mass  securely  seated  on  the  gingival  wall 
and  locked  between  the  buccal  and  lingual  walls.  A  filling  thus 
started  in  a  cavity  of  proper  fomi  cannot  by  any  means  be  made  to 
rock  or  loosen  with  subsequent  manipulation.  It  is  firmly  seated 
on  a  flat  base  and  supported  laterally  by  perpendicular  walls,  so 
that  there  is  no  possibility  of  tipping,  provided  the  gold  has  been 
well  adapted  and  made  dense.  The  virtue  of  creating  angles  to 
join  the  walls  of  these  cavities,  as  advocated  in  considering  their 
preparation,  is  now  especially  apparent  to  the  operator  as  he  starts 
the  filling.  There  is  a  sense  of  security  to  his  work  obtainable  in 
no  other  way. 

The  building  of  the  filling  from  this  stage  to  the  point  where  the 
proximal  portion  of  the  cavity  joins  the  occlusal  anchorage  step 
is  simply  a  process  of  laying  the  cohesive  cylinders  on  the  gold 
already  in  place  ^Wth  their  ends  looking  buccally  and  lingually,  and 
malleting  finnly  to  place.  These  cylinders  should  be  wide  enough 
to  reach  from  the  axial  wall  to  the  matrix,  and  the  filling  should 
be  kept  as  high  along  the  matrix  as  along  the  axial  wall.  "When 
a  cylinder  is  placed  near  the  buccal  or  lingual  wall  the  end  should 
be  turned  slightly  up  against  this  wall,  so  that  when  condensed  it 
will  leave  the  filling  a  trifle  higher  along  these  walls  than  at  other 
points.  This  is  to  insure  the  possibility  of  directing  the  plugger 
against  these  walls,  and  also  to  avoid  the  danger  of  leaving  a 
pocket  between  the  condensed  gold  as  it  approaches  the  occlusal 
surface  and  any  possible  overhang  wliich  may  exist  in  the  cavity  at 
this  point.  This  overhang  relates  to  two  conditions,  either  where 
it  has  not  been  possible  to  make  the  cavity  as  wide  bucco-lingually 
at  the  marginal  ridge  as  at  the  gingival  margin,  or  where  decay  has 
so  eaten  up  under  the  cusps  that  an  arch  is  formed  to  the  cavity 
under  which  the  gold  must  be  adapted.  It  is  not  always  possible 
or  at  all  advisable  to  cut  up  through  this  arch  so  as  to  create  a 


206  PEINCIPLES    AND    PRACTICE    OF    FILLII^G    TEETH. 

perpendicular  wall  to  the  cavity  for  facility  in  building  the  gold. 
ISTeither  of  these  forms  of  cavities  may  be  considered  ideal,  but  in 
the  mouth  we  must  meet  the  issue  of  reality  as  well  as  ideality.  In 
cavities  thus  formed  the  gold  must  be  kept  higher  along  the  buccal 
and  lingual  walls  than  at  any  other  point,  and  if  a  pocket  should  be 
encountered  on  approaching  the  occlusal  aspect  of  the  cavity  some 
non-cohesive  gold  should  be  wedged  into  it. 

A  modification  of  this  method  of  building  the  gold  may  be  ad- 
vantageously followed  in  those  cases  where  the  cayitj  is  broader 
bucco-lingually  at  the  occlusal  surface  than  at  the  gingival  mar- 
gin. In  such  cavities  the  buccal  and  lingual  walls  diverge  as  they 
approach  the  occlusal  surface,  thus  presenting  an  open  aspect  to  the 
cavity  which  renders  the  buccal  and  lingual  walls  easily  accessible 
at  all  points.  With  a  cavity  so  formed  the  gold  may  be  kept  a^ 
high  in  the  central  portion  of  the  filling  as  at  the  buccal  and  lingual 
walls,  or  it  may  even  be  a  trifle  higher  in  the  center  so  as  to  dip 
down  slightly  toward  these  walls.  Into  the  angle  thus  formed 
between  the  walls  and  the  filling  cylinders  may  be  so  wedged  as 
to  most  effectively  lock  the  gold  between  the  buccal  and  lingual 
walls,  and  lend  a  security  and  solidity  to  the  filling  unattainable 
in  any  other  way. 

When  the  filling  is  level  with  the  anchorage  step  on  the  occlusal 
surface  a  cylinder  should  be  laid  with  ends  looking  mesially  and 
distally,  one  half  over  the  gold  already  in  place  and  the  other 
extending  into  the  step.  After  this  is  condensed  another  cylinder 
should  be  laid  in  the  same  way  a  little  farther  along  the  step,  but 
still  lapping  the  condensed  gold,  and  this  process  continued  till  the 
base  of  the  step  is  covered.  By  this  arrangement  of  the  cylinders 
the  proximal  portion  of  the  filling  is  most  securely  locked  into 
the  step.  The  malleting  should  be  especially  thorough  along  the 
angle  formed  by  the  base  of  the  step  with  the  surrounding  walls, 
and  from  this  point  to  the  completion  of  the  filling  each  cylinder 
should  be  carefully  laid  on  its  side  precisely  at  the  point  where  it 
is  intended  to  condense  it;  and  this  cylinder  should  be  made  per- 
fectly compact  before  another  is  added.  This  conduces  to  an  even 
and  uniformly  dense  surface  to  the  filling. 


INTRODUCTIOX    AXD    FIXI8HIXG    OF    GOLD    FILLINGS.  207 

As  lias  previously  been  intimated,  there  is  one  point  in  building 
these  lilliugs  which  requires  especial  attention  with  relation  to  its 
density.  While  the  gold  is  being  built  against  the  matrix-wall, 
and  the  matrix  is  thus  forced  against  the  contact-point  of  the 
proximating  tooth,  the  greatest  care  should  be  exercised  in  mal- 
leting  the  gold  firmly  against  the  matrix  in  this  region  to  insure  a 
hard,  dense  contact-jioint  on  the  J&lling.  The  ability  to  accomplish 
this  with  ease  forms  a  not  unimportant  argument  in  favor  of  the 
matrix  for  these  distal  fillings. 

Pluggers. 

The  form  of  plugger  found  most  serviceable  for  carrying  the 
non-cohesive  gold  to  place  in  starting  the  filling  is  found  in  Fig.  92. 
This  plugger  is  large  enough  to  carry  the  non-cohesive  gold  in 

Fig.  U2. 


front  of  it  instead  of  puncturing  it.  The  serrations  are  compara- 
tively coarse  and  deep,  thus  leaving  an  indented  surface  on  the 
gold  to  facilitate  the  interlacing  of  the  cohesive  with  the  non- 
cohesive.  The  shank  is  heavy  and  rigid,  permitting  of  great  force 
without  springing;  and  the  curve  is  such  that  the  gingival  wall  of 
most  cavities  can  readily  be  reached  with  it. 

For  forcing  the  first  pieces  of  cohesive  gold  to  place  in  the  angles 
Fig.  84  is  admirably  adapted,  and  in  cavities  which  are  narrow 
mesio-distally  most  of  the  filling  may  be  built  up  with  it.  It  is 
also  especially  useful  along  the  matrix-wall.     In  cavities  of  broader 


208  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

area  the  form  illustrated  in  Fig.  93  may  be  utilized,  except  for  tho 
angles  or  against  the  matrix.  These  rounded  forms  are  not  in- 
dicated along  straight  perpendicular  walls,  but  for  building  the 
main  body  of  the  filling  they  are  sometimes  very  useful. 

In  cavities  far  back  in  the  mouth  the  curve  in  Fig.  93  will  not 
always  be  found  great  enough,  and  in  this  event  Fig.  94  may  be 
utilized.  This  will  reach  where  Fig.  93  will  not.  But  even  with 
this  plugger  there  are  many  places  in  these  distal  cavities  which 
cannot  be  reached  with  mallet  force  at  all,  and  then  resort  must  be 
had  to  right-angle  pluggers  and  hand  pressure.  A  convenient  size 
for  this  is  shown  in  Fig.  95.  This  plugger  may  be  used  along  the 
buccal  and  lingual  walls  of  these  cavities,  and,  in  fact,  in  any 
position  not  accessible  to  mallet  force. 

One  great  aid  to  the  building  of  these  disto-occlusal  fillings  on 
the  left  lower  teeth  relates  to  the  position  taken  by  the  operator. 
It  is  frequently  of  the  greatest  possible  advantage  to  go  around  to 
the  left  side  of  the  patient  and  approach  the  cavity  from  this  as- 
pect. This  will  often  bring  the  cavity  into  more  perfect  view  and 
give  better  access  with  the  plugger.  The  lingual  wall  will  ordi- 
narily by  this  means  be  so  presented  to  the  operator  that  he  can 
mallet  his  gold  directly  against  it. 

The  point  of  all  others  where  failure  in  adaptation  to  walls  is 
most  often  manifest  in  these — as,  in  fact,  in  all  disto-occlusal  cavi- 
ties on  the  lower  teeth — is  along  the  wall  which  stands  nearest  to 
the  operator.  The  lingual  wall  on  the  left  side  of  the  mouth  often 
suffers  in  this  particular  unless  the  operator  avails  himself  of  the 
advantage  of  condensing  from  the  left  side  of  the  patient  at  such 
intervals  in  the  work  as  may  seem  desirable.  This  practice  will 
also  be  found  effective  in  those  cases  on  the  molars  where  the 
occlusal  portion  of  the  cavity  involves  the  fissures  so  as  to  extend 
across  the  tooth  bucco-lingually  and  pass  between  the  mesial  and 
distal  cusps.,  The  wall  of  the  cavity  which  stands  nearest  the 
mesio-lingual  cusp  cannot  be  reached  by  mallet  force  from  the 
right  side  of  the  patient,  but  by  passing  to  the  left  the  operator 
may  get  convenient  access  to  it.  In  working  from  the  left  side  the 
mirror  should  be  used  in  the  left  hand,  to  hold  back  the  angle  of 


IXTRODUCTIOX    AND    FINISHING    OF    GOLD    FILLINGS.  209 

the  mouth  and  reflect  light  into  the  cavity,  while  the  plugger  is 
being  used  in  the  right.  The  pluggers  indicated  for  this  work 
must  be  suggested  by  the  demands  of  the  particular  case,  but  or- 
dinarily such  forms  as  Figs.  84  and  94  will  be  found  effective. 
The  latter  is  especially  useful  in  building  the  bulk  of  many  of  these 
large  fillings,  on  account  of  the  reach  occasioned  by  the  curve  in  the 
shank  and  the  angle  at  which  it  is  thus  possible  to  present  the  ser- 
rated end  to  the  gold. 

Finishing   the   Filling". 

When  the  matrix  is  removed  a  thin  burnisher  should  be  used  to 
go  along  the  margins  and  press  down  the  slight  excess  of  gold  over 
the  enamel,  after  which  a  narrow  finishing  strip  may  be  passed  into 
the  interproximal  space  and  the  gingival  portion  of  the  filling 
dressed  even  mth  the  surface  of  the  tooth.  On  account  of  the 
close  contact,  it  will  ordinarily  be  found  impossible  to  force  this 
strip  between  the  teeth  from  the  occlusal  aspect,  in  event  of  which 
it  may  be  passed  end-foremost  into  the  space  from  the  buccal  as- 
pect. When  the  ends  are  drawn  forward  in  the  mouth  they  are 
readily  grasped  by  the  fingers  of  the  operator,  and  are  more  con- 
veniently manipulated  than  is  possible  where  an  attempt  is  made  to 
use  a  strip  on  a  mesial  filling.  The  strips  used  should  be  narrow 
enough  to  play  back  and  forth  in  the  space  without  danger  of  dress- 
ing down  the  contact-point. 

When  the  gingival  portion  of  the  filling  is  perfectly  finished,  a 
sand-paper  disk  may  be  used  in  the  engine  to  play  along  the  buccal 
and  lingual  margins  as  they  approach  the  occlusal  surface  and 
dress  the  filling  even  with  the  surface  of  the  tooth,  but  the  disk 
should  not  be  allowed  to  pass  between  the  teeth,  through  danger 
of  cutting  down  the  contact-point  and  creating  a  flat  surface.  The 
disk  may  also  be  used  to  advantage  to  smooth  that  portion  of  the 
occlusal  surface  of  the  filling  which  slopes  from  the  contact-point 
up  toward  the  cusps,  by  tipping  the  disk  slightly  and  forcing  it  into 
po.sition  with  a  ball  burnisher. 

To  polish  the  proximal  surface  of  the  filling  immediately  at 
the  contact-point  a  broad,   fine  finishing  strip  should  be  used, 

14 


210  PEII^CIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

merely  with  the  abject  of  smoothing  the  gold,  without  cutting  it 
away.  If  the  filling  is  so  tight  against  the  proximating  tooth  that 
even  a  thin  strip  cannot  be  passed  between  the  teeth,  a  separator 
may  be  employed  to  gain  the  slight  space  necessary,  or,  if  this  is  not 
practicable,  the  broad,  thin  burnisher  previously  mentioned  in  con- 
nection with  the  finishing  of  proximal  fillings  in  incisors  may  be 
forced  between  the  teeth  and  manipulated  with  a  rotating  motion 
till  the  gold  is  burnished  smooth  and  the  way  cleared  for  the  intro- 
duction of  the  polishing  strip.  This  broad  burnisher  will  be  found 
very  serviceable  in  all  these  contour  fillings  where  contact  is  close, 
and  it  should  be  in  the  hands  of  every  operator. 

When  the  proximal  surface  of  the  filling  is  thus  dressed  to 
form  and  polished,  the  rubber  dam  should  at  once  be  removed  and 
the  occlusal  surface  ground  to  form  with  corundum  stones  kept 
moist.  The  patient  should  be  instructed  to  close  the  jaws  fre- 
quently to  test  the  necessary  fullness  to  which  the  filling  may  be 
left  "Without  interfering  with  the  occlusion,  and  in  the  event  of  a 
sharp  cusp  from  the  opposing  tooth  striking  so  far  into  the  filling  as 
to  necessitate  grinding  it  too  thin,  it  is  always  advisable  to  shorten 
the  cusp  of  the  opposing  tooth  somewhat  rather  than  make  the 
filling  weak  and  render  the  filled  tooth  subject  to  the  danger  of 
being  split  in  mastication.  When  the  filling  is  ground  to  the 
l^roper  form  with  the  stone  it  may  be  finished  with  a  moose-hide  or 
rubber  point  carrjdng  moistened  pumice  till  all  the  scratches  left 
by  the  stone  are  removed,  after  which  a  high  polish  may  be  given  it 
with  whiting., 

Disto-Occlusal  Fillings  in  the  Right  Lower  Bicuspids  and  Molars. 

The  same  general  plan  of  building  these  fillings  may  be  followed 
as  has  been  suggested  for  the  left  side  of  the  mouth,  except  in  one 
important  particular.  The  buccal  wall  of  these  cavities  on  the 
right  side  of  the  mouth  is  almost  invariably  inaccessible  to  mallet 
force,  and  it  would  therefore  seem  necessary  to  build  the  filling 
along  this  wall  by  hand  pressure  with  a  plugger  formed  like  Fig. 
95.  This  should  be  grasped  in  the  palm  of  the  hand  and  the  gold 
vigorously  pulled  against  the  buccal  wall,  and  particularly  into  the 


INTRODUCTION    AND    FINISHING    OF    GOLD    FILLINGS.  211 

angle  formed  by  the  junction  of  the  buccal  with  the  axial  wall. 
Occasionallv  it  will  be  found  necessary  in  teeth  far  back  in  the 
mouth  to  build  the  entire  gingival  third  of  the  filling  with  hand 
pressure,  but  ordinarily  mallet  force  may  be  employed  on  all  parts 
of  the  filling  from  the  gingival  wall  up,  except  along  the  buccal 
wall. 

Another  point  where  right-angle  hand  pressure  is  indicated  in 
these  fillings  is  in  the  angle  formed  by  the  base  of  the  anchorage 
step  and  the  mesial  wall  of  the  step.  This  is  a  wall  which  looks 
away  from  the  operator,  and  the  base  of  the  step  cannot  be  seen 
at  this  point  except  with  the  mirror..  It  is  therefore  impossible  to 
reach  it  with  direct  mallet  force,  and  the  strong  right-angle  plug- 
ger  should  be  employed  to  lock  the  gold  into  this  angle  and  build 
it  up  to  the  point  where  the  mallet  blow  is  effective.  Unless  this 
precaution  be  taken,  there  is  quite  likely  to  be  a  bridging  of  the 
gold  over  the  angle  and  a  subsequent  leak  in  the  filling. 

Disto-Occlusal  Fillings  in  Tipper  Bicuspids  and  Molars. 

The  plan  of  building  these  fillings  is  practically  the  same  as  for 
lower  teeth,  except  that  mallet  force  may  be  more  uniformly  used 
here  than  on  the  lower  jaw.  Except  in  rare  cases,  the  only  place 
where  the  mallet  may  not  be  used  after  the  filling  is  started  is  along 
the  buccal  wall  of  cavities  on  the  left  side  of  the  mouth.  Here 
it  is  often  necessary  to  work  by  the  aid  of  the  mirror  and  adapt 
the  gold  with  a  large  right-angle  plugger  grasped  in  the  palm. 

For  the  bulk  of  the  work,  when  the  filling  has  reached  the  point 
where  mallet  force  may  be  used,  such  forms  as  Fig's.  84,  93,  and  94 
will  l)e  found  effective. 

Mesio-Occlusal  Fillings  in  Bicuspids  and  Molars. 

The  same  arrangement  of  gold  may  be  followed  in  building  these 
fillings  as  for  disto-occlusal  surfaces,  except  that  in  mesial  fillings 
mallet  force  is  almost  universally  applicable.  The  better  access  to 
this  kind  of  a  cavity  would  seem  to  render  these  fillings  more 
easily  inserted  than  distal  ones,  but  there  is  one  counter  difficulty 
which  l)ecomes  important  unless  it  is  fully  appreciated  and  the 


212 


PKINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 


Fig.  96. 


proper  means  taken  to  avoid  it.  This  relates  to  the  finishing  of 
the  filling  along  the  gingival  third  of  the  proximal  surface.  As 
has  already  been  staited,  it  is  exceedingly  difficult  to  manipulate  a 
strip  so  as  to  cut  against  the  mesial  surfaces  of  these  fillings.  The 
ends  of  the  strip  cannot  ordinarily  be  carried  far  enough  back  in 
the  mouth  to  work  effectively  in  the  cutting  of  any  great  surplus 
of  gold.  The  most  that  can  be  done  is  to  smooth  the  filling  after 
it  is  of  the  proper  form. 

It  is  therefore  of  the  greatest  importance  that  the  filling  when 
condensed  shall  present  as  nearly  as  possible  the  form  it  should 
assume  when  finished,  and  to  this  end  a  matrix  should  be  used 
along  the  gingival  third  of  the  cavity  to  give  the  filling  the  most 
desirable  form  while  it  is  being  built.  A  little 
time  and  care  in  the  proper  adjustment  of  the 
matrix  will  be  amply  repaid  in  the  facility  with 
which  such  a  filling  may  be  finished.  In  those 
cases  where  it  is  found  that  an  appreciable  surplus 
of  gold  has  been  built  over  the  gingival  margin  so 
that  its  removal  with  the  strip  would  be  found  a 
tedious  and  ineffective  process,  or  in  the  instance 
of  a  tooth  with  a  concavity  on  the  proximal  sur- 
face of  the  neck,  as  in  an  upper  bicuspid  where 
the  strip  will  not  reach,  the  gold  may  be  dressed 
to  form  with  files  or  with  keen-bladed  trimmers.  A  suitable  form 
of  file  for  this  purpose  is  found  in  the  Rhein  proximal  trimmei's 
(Tig.  96),  which  mil  reach  between  the  teeth  into  the  concavity 
and  readily  reduce  the  surplus.  The  effectiveness  of  these  files 
may  be  greatly  increased  if,  following  a  suggestion  of  the  late 
Dr.  George  H.  Gushing,  the  blades  are  sharpened  and  cut  with  the 
same  care  that  is  bestowed  on  the  blades  of  a  bur.  Prepared  in  this 
way  they  take  hold  of  the  gold  with  a  definite  grip  and  peel  it  off 
rapidly,  leaving  a  smooth  surface. 

Occlusal  Fillings  in  Bicuspids  and  Molars. 
The  plan  of  building  these  fillings  varies  somewhat  according  to 
the  extent  and  form  of  the  cavity.     A  narrow  deep  cavity  calls  for 


INTRODUCTIOJf    AND    FINISHING    OF    GOLD    FILLINGS.  213 

an  arrangement  of  the  pellets  of  gold  different  from  that  of  a  broad 
and  comparatively  shallow  cavity.  In  the  narrow  cavity  the  en- 
tire area  of  the  piilpal  wall  or  seat  may  be  covered  by  the  first  piece 
of  gold  inserted  so  that  it  is  wedged  between  the  surrounding  walls, 
and  the  filling  may  grow  from  this  in  regular  layers  at  right  angles 
with  the  long  axis  of  the  tooth  till  the  cavity  is  full.  In  a  broad 
cavity  this  is  not  practicable.  The  filling  must  be  started  in  one 
exti-emity  of  the  cavity  and  carried  across  the  pulpal  wall  pellet  by 
pellet,  till  a  sufficient  number  have  been  placed  to  reach  from  one 
perpendicular  wall  to  another. 

The  idea  in  fastening  these  fillings  in  position  against  possible 
dislodgment  is  to  securely  lock  the  gold  between  the  surrounding- 
walls  of  the  cavity  and  into  the  angle  formed  by  the  junction  of 
these  walls  with  the  pulpal  wall  or  seat.  If  these  angles  are 
formed  on  correct  mechanical  principles  and  the  pulpal  wall  is 
made  flat,  as  suggested  in  considering  cavity  preparation,  the  gold 
may  be  inserted  with  the  greatest  facility  and  the  filling  anchored 
beyond  the  possibility  of  displacement  under  stress  of  mastication. 
The  wear  on  these  fillings  is  often  very  severe,  and  the  gold,  in 
order  to  do  the  most  permanent  service,  must  not  only  be  perfectly 
adapted  to  the  walls,  but  must  be  made  dense  and  hard.  As  has 
already  been  stated,  the  hardness  of  gold  can  be  largely  increased 
by  continued  malleting,  even  after  compactness  has  been  reached, 
and  in  the  insertion  of  these  fillings  the  operator  should  take  advan- 
tage of  this  fact  in  order  to  secure  as  perfect  a  wearing  surface  to 
his  fillings  as  possible.  As  the  last  pieces  of  gold  are  added  the 
malleting  should  be  carried  somewhat  beyond  the  point  of  compact- 
ness, until  the  operator  can  detect  a  hard,  metallic  ring  to  the  sur- 
face of  the  filling.  This  does  not  imply  prolonged  or  injudicious 
hammering  on  the  gold  to  the  injury  of  the  peridental  membrane 
or  the  enamel-margins.  Care  should  be  exercised  not  to  go  beyond 
the  necessities  of  the  case,  but  the  idea  should  ever  be  present  that 
these  fillings,  of  all  others,  require  the  greatest  density  and  the 
highest  degree  of  resisting  power. 

If  an  operator  will  consider  carefully  the  amount  of  aggregate 
service  which  such  a  filling  is  likely  to  be  called  upon  to  perform  in 


214  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

the  course  of  its  allotted  life,  he  will  be  more  seriously  impressed 
with  the  necessity  for  the  greatest  care  and  thoroughness  in  its 
condensation.  The  repeated  impact  in  the  process  of  mastication 
aggregates  enormously  in  a  single  year,  and  a  filling  inserted  in 
the  mouth  of  an  individual  of  early  or  middle  life  with  an  expect- 
ancy of  twenty,  thirty,  or  even  forty  years'  semdce  must  needs  be 
of  the  highest  order  of  excellence  to  meet  the  requirements.  As 
has  already  been  intimated,  the  proper  mastication  of  an  ordinary 
meal  involves  at  least  one  thousand  occlusions.  Supposing  that 
the  force  of  one-half  or  even  one-fourth  of  these  falls  on  a  certain 
tooth,  the  number  of  impacts  on  that  tooth  in  the  course  of  a 
twelvemonth  is  seen  to  be  very  great.  Multiply  this  by  the  num- 
ber of  years  such  a  tooth  is  likely  to  be  called  on  for  service,  and 
the  sum  becomes  well-nigh  appalling.  The  force  of  these  impacts 
varies  in  different  mouths,  and  there  is  also  a  considerable  range 
in  the  degree  required  for  the  comminution  of  the  different  kinds 
of  food  material  in  the  same  mouth;  but  the  lowest  force  neces- 
sary for  ordinary  mastication  is  at  least  great  enough  to  become 
an  important  factor  in  determining  the  degree  of  density  required 
of  a  filling  against  which  it  is  brought  to  bear. 

In  an  extended  study  of  the  greatest  possible  force  that  could  be 
exerted  by  closure  of  the  human  jaws,  Dr.  G.  V.  Black  found  that 
upon  the  molars  it  ranged  from  twenty-five  pounds  to  three 
hundred  pounds,  and  that  the  force  in  common  use  in  mastica- 
tion was  greatly  in  excess  of  preconceived  ideas  on  the  subject. 

Suppose,  then,  a  filling  on  the  occlusal  surface  of  a  lower  molar 
with  the  cusp  of  an  upper  molar  occluding  directly  against  it,  and 
this  filling  at  each  meal  receiving  the  impact  of  the  upper  cusp 
crushing  food-material  between  it  and  the  filling  at  the  rate  esti- 
mated, it  will  readily  become  apparent  that  to  do  permanent  service 
the  material  of  which  the  filling  is  made  must  be  capable  of  with- 
standing considerable  wear. 

The  reason  that  many  fillings -of  poor  structure  have  been  known 
to  save  teeth  for  years  is  accounted  for  in  the  fact  that  they  have 
been  so  situated  with  relation  to  the  opposing  tooth  that  the  par- 
ticular filling  in  question  has  not  received  the  full  force  of  masti- 


IXTRODUCTION    AND    FINISHIXG    OF    GOLD    FILLINGS.  215 

eatery  usage,  but  such  a  possible  coutingencj  as  this  should  not 
deter  an  operator  from  making  his  fillings  uniformly  of  the  highest 
degree  of  excellence.  If  we  could  have  the  record  of  all  the  fill- 
ings which  have  failed  as  the  result  of  imperfect  condensation,  and 
place  it  beside  the  number  of  such  fillings  that  have  succeeded,  the 
evidence  would  be  overwhelmingly  in  favor  of  dense  fillings. 

Insertion  of  Gold  in  Occlusal  Cavities  in  Lower  Molars. — ■ 
Usually  these  cavities  are  so  large  in  area  that  the  gold  must  be 
started  in  one  extremity  of  the  cavity  and  carried  across  the  pulpal 
wall  toward  the  other  extremity  piece  by  piece,  instead  of  wedging 
from  one  wall  to  the  other  at  the  beginning.  Fillings  of  this  char- 
acter should  ordinarily  be  started  in  that  portion  of  the  cavity  most 
remote  from  the  operator,  and  built  progressively  toward  the  wall 
nearest  him.  A  rope  of  non-cohesive  gold  should  first  be  carried 
into  the  angle  formed  by  the  junction  of  the  distal  wall  of  the 
cavity  with  the  pulpal  wall  or  seat,  and  into  this  non-cohesive  gold 
should  be  forced  a  cylinder  of  cohesive  gold  and  the  whole  mass 
driven  to  place  with  hand  pressure,  followed  by  the  mallet.  The 
cohesive  cylinders  should  now  be  added  one  after  the  other,  with 
their  sides  against  the  mass  of  gold  already  in  place,  and  each 
cylinder  condensed  by  mallet  force  over  its  entire  surface.  The 
ends  of  the  cylinders  should  look  toward  the  pulpal  wall  and  the 
occlusal  surface  of  the  filling,  except  that  as  the  filling  is  being- 
built  forward  the  portion  near  the  pulpal  wall  should  be  slightly 
in  advance  and  extend  farther  toward  the  mesial  than  that  at  the 
occlusal  surface.  This  presents  an  inclined  surface  of  gold  to  the 
operator  against  which  the  plugger  point  may  have  a  direct  l)ear- 
ing,  and  the  cylinders  should  be  laid  with  their  sides  upon  this 
incline.  Each  cylinder  should  be  long  enough  if  possible  to  reach 
from  the  pulpal  wall  to  the  extreme  elevation  of  the  occlusal  sur- 
face of  the  filling. 

As  the  point  is  reached  where  the  cavity  widens  out  buccally 
and  lingually  between  the  mesial  and  distill  cusps,  care  should  be 
exercised  to  wedge  the  gold  securely  into  the  angles  formed  by  the 
junction  of  the  pulpal  wall  with  the  lingual  and  buccal  extremities 
of  the  cavity.     These  portions  of  the  filling  are  sometimes  lifted 


216  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

out  of  place  by  the  use  of  adhesive  materials  such  as  sticky  candy, 
etc.,  unless  the  precaution  is  taken  to  so  deepen  the  cavity  at  these 
points  as  to  afford  ample  retention,  and  then  condense  the  gold 
firmly  into  place. 

'  There  are  two  points  from  this  to  the  completion  of  the  filling 
which  demand  especial  attention, — the  wall  which  looks  toward  the 
mesio-lingual  cusp  on  left  lower  molars  and  the  mesio-buccal  cusp 
on  right  lower  molars,  and  also  the  mesial  extremity  of  cavities  on 
either  side  of  the  mouth.  Unless  the  operator  be  very  cautious, 
these  places  will  be  bridged  over  and  the  filling  fail  of  perfect 
adaptation  and  density.  As  has  already  been  intimated,  the  diffi- 
culty of  approaching  these  walls  by  mallet  force  on  the  left  side  of 
the  mouth  may  be  largely  overcome  by  operating  from  the  left  side 
of  the  patient,  but  on  the  right  side  there  is  no  alternative  except 
to  use  curved  pluggers  and  pull  the  gold  into  position. 

When  the  walls  are  protected  and  the  filling  built  fiush  with  the 
masticating  surface,  the  entire  area  of  exposed  gold  should  be 
thoroughly  malleted  to  perfect  density.  This  may  be  done  with 
pluggers  of  shallow  serrations  or  no  serrations  at  all,  and  the  final 
blows  of  the  mallet  should  be  struck  along  the  margins  of  the 
filling. 

Insertion  of  Gold  in  Occlusal  Cavities  in  Upper  Molars. — 
These  cavities  are  usually  of  such  an  area  that  the  first  piece  of  gold 
inserted  may  be  made  to  cover  the  entire  pulpal  wall  so  as  to  wedge 
between  the  surrounding  walls.  A  non-cohesive  rope  of  sufficient 
size  to  fill  about  one-third  of  the  cavity  should  be  used  to  start  the 
filling,  and  into  this  the  cohesive  cylinders  may  be  interlaced  till 
the  two  forms  of  gold  are  locked  together.  When  the  filling  is 
nearly  completed  the  cylinders  should  be  carefully  laid  in  regular 
layers,  with  their  sides  upon  the  filling  already  in  place  and  con- 
densed with  pluggers  having  shallow  serrations,  to  the  end  that  the 
surface  of  the  filling  may  be  made  uniformly  dense  and  even. 

In  those  long,  narrow  fissure  cavities,  such  for  instance  as  those 
which  follow  the  disto-lingual  groove,  the  filling  should  be  started 
in  one  extremity  of  the  cavity  and  built  progressively  across  to  the 
other  extremity,  but  the  same  principle  of  wedging  the  gold  be- 


INTRODUCTIOIV    AND    FIXISHIXG    OF    GOLD    FILLINGS.  217 

tween  the  two  lateral  walls  of  the  cavity  should  be  followed 
throughout.  The  fact  should  never  be  lost  to  view  that  in  the 
insertion  of  all  gold  fillings,  no  matter  where  located,  the  prime 
requisite  for  success  is  adaptation  of  the  gold  to  the  walls.  This  is 
more  important,  if  possible,  even  on  these  occlusal  surfaces,  than  a 
high  degree  of  density,  and  yet  the  thorough  and  careful  operator 
will  not  stop  short  of  securing  perfect  adaptation  and  high  density. 

Insertion  of  Gold  in  Occlusal  Cavities  in  Bicuspids. — The 
most  difficult  fillings  to  insert  successfully  on  any  of  the  occlusal 
surfaces  are  those  in  the  small  round  pit  cavities  sometimes  found 
on  lower  bicuspids.  They  appear  to  be  the  simplest  possible  form 
of  cavity  to  fill,  and  yet  they  really  demand  a  higher  order  of  skill 
than  cavities  of  much  larger  area.  Unless  the  cavity  has  well- 
defined  angles  and  a  flat  pulpal  wall  the  gold  has  a  tendency  to  roll 
under  pressure,  and  there  seems  to  be  an  especial  difficulty,  par- 
ticularly with  beginners,  in  securing  good  adaptation  to  the  walls  of 
these  round  holes.  Then  in  some  instances  the  occlusal  portion  of 
the  filling  is  inclined  to  loosen  as  the  final  malleting  is  being  done 
and  come  away  from  the  gold  in  the  depth  of  the  cavity,  leaving  a 
little  peg  of  gold  to  which  it  seems  almost  impossible  to  attach  any 
fresh  gold. 

The  proper  method  of  inserting  these  fillings  is  to  use  a  mass  of 
non-cohesive  gold  of  sufficient  size  to  fill  at  least  one-half  of  the 
cavity,  and  force  a  round  plugger  slightly  less  in  area  than  the 
cavity  into  the  center  of  tlie  mass  and  wedge  it  in  every  direction 
with  hand  pressure  wielded  in  the  swaying  motion  before  referred 
to.  This  leaves  a  depression  in  the  middle  of  the  filling,  with  some 
non-coliesive  gold  standing  up  against  the  surrounding  walls  of  the 
cavity.  A  small  cylinder  of  cohesive  gold  should  now  be  wedged 
into  the  depression  in  the  non-cohesive  gold  with  hand  pressure, 
and  the  whole  mass  forced  in  all  directions, — toward  the  pulpal 
wall  and  against  the  surrounding  walls.  The  pressure  should  be 
very  vigorous,  but  the  manipulation  must  not  be  kept  up  too  long 
through  fear  of  overworking  the  surface  and  rendering  it  difficult 
to  attach  more  gold  to  it.  Most  of  the  filling  should  thus  be  built 
up  by  hand  pressure  on  the  wedging  principle,  and  the  mallet  used 


218  PRI]S'CIPLES    A'SD    PRACTICE    OF    FILLING    TEETH. 

only  on  the  immediate  sui'face.  If  this  plan  be  followed  the 
operator  will  secure  good  adaptation  to  the  walls  through  the 
medium  of  the  non-cohesive  gold,  and  the  two  kinds  of  gold  will 
be  so  wedged  or  interlaced  together  that  the  surface  of  the  filling 
will  not  flake  off. 

In  cavities  long  and  narrow,  such  as  are  ordinarily  found  on 
uj)j)er  bicuspids  and  on  lower  second  bicuspids,  the  method  of 
inserting  the  gold  is  the  same  as  for  similarly  formed  cavities  on 
molars.  The  gold  should  be  started  in  the  distal  region  of  the 
cavity  and  built  across  to  the  mesial.  The  point  in  these  fillings 
requiring  especial  care  in  adaptation  is  in  the  angle  formed  by  the 
junction  of  the  mesial  with  the  pulpal  wall.  Unless  the  operator 
Avatch  this  angle  carefully,  he  will  be  likely  to  bridge  the  gold  over 
it  and  leave  an  imperfection  in  the  filling. 

Finishing  Gold  Fillings  on  the  Occlusal  Surfaces  of  Bicuspids 
and  Molars. — As  soon  as  the  filling  is  thoroughly  condensed  it  is 
ordinarily  well  to  remove  the  rubber  dam  before  finishing.  The 
operator  should  make  it  a  rule  not  to  encumber  his  patient  longer 
than  possible  with  this  necessary  but  disagreea;ble  adjunct  to  the 
operation,  especially  in  view  of  the  fact  that  these  fillings  can 
usually  better  be  finished  without  it.  The  most  effective  means  of 
dressing  the  filling  to  form  is  by  the  use  of  corundum  stones  in  the 
engine,  and  these  should  invariably  be  kept  moist  to  facilitate  the 
cutting  of  the  stone  and  to  prevent  heat.  The  form  of  stone  best 
adapted  for  most  cases  is  the  wheel,  and  they  should  range  in  sizes 
from  a  very  large,  thick  wheel  to  a  small,  narrow  form  to  meet  the 
varying  cases  presented.  Care  should  be  taken  to  test  the  occlusion 
by  repeated  closure  of  the  teeth,  to  be  assured  that  the  filling  is  not 
left  so  high  that  an  opposing  cusp  impinges  too  hard  upon  it. 

When  the  filling  is  ground  to  the  desired  form  it  Avill  be  found 
that  the  stone  has  left  its  surface  covered  with  scratches,  which 
must  be  removed  in  order  to  give  it  a  finished  appearance.  This 
may  ordinarily  best  be  done  with  moistened  pumice  carried  on  a 
moose-hide,  leather,  or  rubber  wheel,  and  when  the  filling  is  per- 
fectly smooth  some  whiting  may  be  substituted  for  the  pumice  and 
a  bright  polish  given  the  surface. 


INTRODUCTION    AND    FINISHING    OF    GOLD    FILLINGS.  2  li) 

In  certain  cases  these  occlusal  fillings  may  be  finished  to  advan- 
tage with  sand-paper  disks  by  tipping  the  disk  at  an  angle  and  com- 
pressing it  into  place  with  a  ball  burnisher.  In  fillings  of  narrow 
area  situated  in  depressions  between  cusps  it  is  often  difiicult  to 
reach  them  with  stones  without  cutting  the  surrounding  enamel. 
In  these  cases  small  finishing  burs  may  be  used  with  short,  sharp 
blades  to  dress  the  filling  to  form,  when  it  may  be  polished  with 
pumice'  and  whiting  on  wood  points  carried  in  the  engine.  In 
other  eases  these  fillings  may  be  advantageously  reached  by  wind- 
ing a  short  finishing  strip  on  a  small  slot  mandrel  in  the  engine. 

Buccal,  Labial,   or  Lingual   Fillings. 

The  same  principles  of  inserting  the  gold  apply  to  these  cavities 
that  have  just  been  advocated  for  occlusal  fillings, — viz,  in  all  cavi- 
ties of  sufiiciently  limited  area  the  first  piece  of  gold  inserted  may 
be  made  to  cover  the  entire  pulpal  wall  and  wedge  between  the 
surrounding  walls,  and  the  filling  built  up  in  regular  layers  parallel 
with  the  pulpal  wall,  while  in  cavities  too  extensive  for  such  an 
arrangement  the  gold  must  be  started  in  an  extremity  of  the  cavity 
and  built  across  the  pulpal  wall  piece  by  piece  toward  the  other 
extremity.  In  either  case  the  chief  requisites  relate  to  perfect 
adaptation  to  cavity-walls  and  a  reasonable  degree  of  density  to  the 
gold.  As  the  surface  of  the  filling  is  approached  the  aim  should 
be  to  lay  the  cylinders  on  in  a  regular  order,  so  as  to  obtain  as 
nearly  as  may  be  an  even  surface  which  will  not  demand  much 
cutting  to  finish  it. 

There  is  one  point  in  the  insertion  of  these  fillings  which  calls 
for  especial  attention, — the  gingival  enamel-margin.  Great  care 
should  be  exercised  as  the  filling  is  being  inserted  to  adequately 
protect  the  margin  without  building  a  large  mass  of  gold  over  it. 
The  slightest  deficiency  of  gold  at  this  point  jeopardizes  the  opera- 
tion and  mars  an  otherwise  perfect  filling,  while  a  great  excess  of 
gold  leads  to  a  peculiarly  irksome  procedure  in  its  removal.  The 
operator  therefore  should  study  carefully  the  outline  of  the  cavity 
as  he  is  inserting  the  gold,  and  should  aim  to  reproduce  the  original 
form  of  the  tooth  with  just  sufficient  excess  of  gold  to  make  cer- 


220  pkijstciples  and  practice  of  filling  teeth. 

tain  of  a  perfect  finish.  A  little  extra  care  at  this  stage  of  the 
operation  will  save  much  time  and  annoyance  subsequently. 

Finishing  the  Filling. — Usually  the  most  effective  means  of 
dressing  these  fillings  to  form  is  to  employ  a  sand-paper  disk  in  the 
engine,  and  for  the  proper  approach  of  the  disk  it  is  ordinarily 
necessary  to  remove  the  clamp.  But  in  every  instance  where  possi- 
ble the  rubber  dam  should  be  left  in  position  till  the  filling  is 
finished,  for  the  purpose  of  keeping  blood  and  saliva  away  from  the 
disk,  and  also  to  afford  protection  to  the  gum  and  avoid  its  lacera- 
tion. The  dam  may  be  held  back  so  as  to  expose  the  filling  with 
the  fingers  of  the  left  hand,  or  by  a  hand  instrument  with  its  point 
pressed  against  the  surface  of  the  tooth  rootwise  of  the  gingival 
margin  of  the  filling.  The  disk  should  be  smeared  with  vaseline 
or  some  suitable  lubricant  to  prevent  heating  the  filling,  and  also  to 
allow  it  to  play  freely  against  the  rubber  dam  without  cutting  or 
catching  in  it  and  rolling  it  up. 

When  the  filling  is  dressed  to  the  proper  form  a  heautif ul  polish 
may  be  given  it  with  a  cuttlefish  disk  or  with  a  small  rubber  cup  on 
a  mandrel  carrying  pumice,  followed  by  whiting.  Care  should  be 
exercised  in  finishing  these  fillings  to  avoid  as  largely  as  possible 
any  undue  laceration  of  the  gums.  Some  slight  irritation  of  the 
free  margin  of  the  gum  is  often  unavoidable,  and  need  not  be  con-" 
sidered  serious,  but  when  the  gum  is  badly  cut  or  torn  it  is  not 
always  reproduced  in  as  perfect  a  condition  as  it  originally  was, 
and  the  healing  is  sometimes  a  slow  and  discouraging  process. 
With  ordinary  precaution  the  gum  may  be  so  protected  from  injury 
as  to  entirely  recover  from  the  operation  in  a  day  or  two,  and  lap 
over  the  gingival  portion  of  the  filling  in  a  healthy  pink  condition. 


MANIPULATION  OF  PLATINUM  AND  GOLD  IN  FILLING  TEETH.      221 


CHAPTEK    X. 

MANIPrLATION    OF    PLATINUM    AND    GOLD    IN    FILLING 

TEETH. 

This  material  comes  to  us  in  two  forms  from  the  manufacturer, 
— in  the  rolled  form  the  same  as  the  heavier  golds,  and  in  the  form 
of  folds  made  from  thinner  foils.  It  is  a  matter  of  individual 
preference  which  form  is  used,  though  for  ordinary  work  the  folds 
will  be  found  a  trifle  more  obedient  to  the  plugger  and  more  easily 
managed  than  the  heavier  forms.  The  folds  are  about  an  inch  in 
Av'idth,  and  may  be  cut  into  strips  of  a  convenient  size  for  the  case 
in  hand.  There  are  three  shades,  1,  2,  and  3,  the  former  having  a 
predominance  of  gold  and  showing  a  decidedly  yellow  color  on  fin- 
ishing, shade  2  containing  a  larger  percentage  of  platinum  and 
showing  more  of  a  platinum  color  than  shade  1,  while  shade  3  gives 
a  decidedly  gray  color  almost  like  pure  platinum.  The  shades  may 
be  varied  in  thfe  mouth  to  suit  the  case. 

The  chief  points  of  distinction  between  the  management  of  gold 
foil  and  the  management  of  platinum  and  gold  relate  to  the  an- 
nealing and  the  method  of  condensing.  Platinum  and  gold  re- 
quires greater  care  in  annealing  to  the  end  that  it  be  not  in  the 
least  overheated,  particularly  if  the  folds  are  used  and  the  anneal- 
ing is  done  in  a  flame.  To  pass  a  strip  through  the  flame  in  the 
ordinary  way  will  almost  invariably  result  in  the  ends  curling  up 
and  the  gold  shade  disappearing  entirely,  leaving  a  pure  platinum 
shade.  These  ends  when  thus  overheated  are  harsh,  unworkable, 
and  wholly  unreliable.  In  every  instance  where  by  any  inad- 
vertence platinum  and  gold  is  so  heated  as  to  change  color  in  this 
way,  it  should  at  once  be  discarded  and  no  attempt  made  to  use  it. 
To  gain  the  best  results  in  the  manipulation  of  platinum  and  gold 
it  should  be  annealed  over  mica  on  the  electric  annealer,  first  plac- 
ing a  piece  of  mica  on  the  annealer  and  allowing  a  slow  steady 
heat  to  thus  i-each  the  material.  If  placed  directly  on  the  an- 
nealer it  will  sometimes  be  found  that  it  will  turn  to  a  platinum 
color. 


222  PKINCIPLES    AND    PKACTICE    OF    FILLING    TEETH. 

In  building  the  filling  witli  this  material  the  operator  must  work 
a  little  slower  and  more  deliberately  than  with  gold.  It  cannot 
safely  be  added  in  as  large  masses  as  gold,  nor  is  it  so  easily  adapted 
to  walls  or  margins.  The  condensation  must  be  very  painstaking 
and  precise,  small  plugger  points  being  used  with  the  serrations 
shallow  but  sharply  cut,  and  each  piece  malleted  perfectly  dense 
before  another  is  added. 

In  view  of  the  more  exacting  nature  of  the  work  it  is  seldom 
advisable  to  utilize  platinum  and  gold  for  the  entire  filling,  the 
most  satisfactory  results  being  obtained  by  employing  gold  for 
starting  the  filling,  and  building  it  to  a  point  along  the  walls  where 
it  approaches  the  exposed  surfaces,  and  then  completing  the  opera- 
tion "with  platinum  and  gold.  This  will  materially  shorten  the 
work  and  produce  the  most  perfect  filling,  on  account  of  the  more 
ready  adaptation  of  gold  to  the  inaccessible  parts  of  the  cavity. 
As  the  first  pieces  of  platinum  and  gold  are  added  to  the  gold 
already  in  place  the  smallest  plugger  points  should  be  used,  and 
the  utmost  care  taken  to  force  the  platinum  and  gold  into  the 
structure  of  the  gold  so  that  the  two  are  incorporated  as  one  mass. 
If  this  precaution  is  taken  the  platinum  and  gold  will  never  sepa- 
rate from  the  gold^  As  the  extreme  surface  of  the  filling  is  ap- 
proached the  folds  should  be  laid  flat  upon  the  filling  in  precisely 
the  place  where  they  are  to  be  condensed,  and  the  malleting  should 
be  very  thorough,  with  the  impact  brought  to  bear  step  by  step 
over  every  part  of  the  surface  area  down  to  the  minutest  points. 
To  omit  even  the  smallest  area  from  this  mallet  impact  means 
that  the  portion  thus  overlooked  is  likely  to  flake  when  the  filling 
is  subjected  to  wear,  and  if  the  operator  desires  a  satisfactory  fill- 
ing free  from  blemishes  he  cannot  give  too  close  attention  to  the 
surface  condensation. 

Platinum  and  gold,  if  thoroughly  and  uniformly  condensed, 
will  take  on  a  beautiful  finish  which  is  not  only  satisfactory  in  its 
wearing  qualities,  but  is  highly  artistic  in  appearance.  In  fact,  it 
may  truly  be  said  that  to  produce  a  perfect  platinum  and  gold 
filling  is  to  attain  the  highest  degree  of  excellence  in  the  art  of  fill- 
ing teeth. 


MAXIPULATIOX    OF    TIX    AND    GOLD.  223 

CHAPTER    XL 

MANIPULATION  OF  TIN  AND  GOLD. 

A  CONVENIENT  method  of  preparing  this  material  is  to  take  a 
sheet  of  Xo.  4  pure  tin  foil  and  lay  upon  it  a  sheet  of  'No.  4  gold 
foil,  cutting  these  in  three  equal  paits,  making  strips  about  an  inch 
in  width.  These  strips  may  then  be  twisted  into  ropes  and  cut  into 
suitable  lengths  for  the  particular  use  intended.  In  twisting  the 
ropes  it  is  Avell  to  so  arrange  the  layei"s  of  foil  that  the  tin  Avill  be 
on  the  outside  of  the  rope,  thus  resulting  in  a  tougher  product  and 
one  easily  adapted  to  cavity-walls. 

For  building  the  gingival  third  of  deep  occluso-proximal  fillings 
in  bicuspids  and  molars,  as  already  suggested,  the  ropes  of  tin  and 
gold  may  be  used  much  in  the  same  manner  that  was  advocated  for 
gold  alone,  except  that  the  plugger  points  should  be  more  coarsely 
serrated,  and  nothing  but  hand  pressure  used  in  forcing  the  tin  and 
gold  to  place.  The  ropes  should  be  vigorously  wedged  to  position 
into  the  angle-s  and  Ijetween  the  cavity-walls,  the  swaying  motion 
of  the  plugger  being  esi^ecially  indicated,  and  the  very  greatest 
amount  of  force  used  consistent  with  safety  to  walls  and  margins. 
One  cardinal  point  in  the  manipulation  of  this  material  should 
never  be  lost  to  view, — the  danger  of  overmanipulation.  The 
plugger  should  be  brought  down  upon  it  at  a  given  point  with  slow, 
strong,  wedging  force,  and  as  large  a  mass  of  the  material  carried 
to  place  as  possible  with  this  one  thrust.  The  next  position  taken 
by  the  plugger  point  should  be  deliberate  and  carefully  directed, 
and  another  area  of  the  mass  condensed  in  the  same  manner.  If 
manipulated  in  this  way  the  material  will  go  to  place  readily  and 
remain  there,  while  the  integrity  of  the  resultant  mass  will  not  be 
impaired,  but  if  the  material  is  in  the  least  degree  overworked  by 
the  plugger  it  chops  up  and  disintegrates  so  as  to  ruin  it.  Many 
operators  have  failed  to  get  satisfactory  results  with  this  material 
on  account  of  overmanipulation. 

After  the  requisite  amount  of  tin  and  gold  has  been  forced  to 


224  PRINCIPLES    AND    PKACTICE    OF    FILLING    TEETH. 

position  with  hand  pressure,  the  surface  will  present  coarse  inden- 
tations resulting  from  the  deep  serrations  of  the  plugger,  and  into 
this  surface  should  be  incorporated  cohesive  gold  cylinders,  using 
the  same  plugger  with  hand  pressure  till  the  gold  reaches  from  the 
buccal  to  the  lingual  wall.  As  soon  as  the  gold  is  securely  locked 
across  between  these  two  walls  and  interwoven  into  the  tin  and 
gold,  the  coarse  plugger  should  be  laid  aside  and  a  plugger  with 
shallower  serrations  substituted  for  it.  Up  to  this  point  the  process 
has  been  one  of  wedging  with  hand  pressure  and  an  interlacing  of 
the  layers  of  tin  and  gold  together,  and  also  of  the  gold  cylinders 
into  the  tin  and  gold.  There  is  no  cohesion  between  the  tin  and 
gold,  nor  between  this  and  the  cohesive  gold,  so  that  they  must  be 
interwoven  in  the  manner  indicated.  But  from  this  point  the 
mallet  should  be  used  and  the  layer  of  cohesive  gold  should  be 
very  vigorously  malleted  down  onto  the  tin  and  gold  till  the  entire 
mass  is  made  compact  and  dense.  From  this  the  filling  is  com- 
pleted Avith  gold  in  the  ordinary  way. 

The  finishing  and  polishing  of  the  tin  and  gold  at  the  gingival 
margin  is  in  no  wise  different  from  that  advocated  for  gold. 

In  filling  occlusal  cavities  in  bicuspids  and  molars  for  children 
with  this  material,  a  rope  should  be  selected  if  possible  large 
enough  to  fill  the  entire  cavity  and  leave  a  sufficient  surplus  for  a 
perfect  finish.  If  the  cavity  is  found  to  be  too  extensive  for  one 
rope  to  fill,  care  should  be  taken  that  the  first  rope  used  shall  not 
be  so  large  as  to  carry  the  filling  too  near  the  occlusal  surface.  In 
other  words,  the  final  rope  should  be  allowed  to  extend  sufficiently 
into  the  cavity  to  be  firmly  locked  between  the  surrounding  walls 
and  be  retained  by  reason  of  this  locking  rather  than  from  any 
union  between  it  and  the  mass  already  in  place.  Tin  and  gold,  as- 
has  been  said,  is  not  cohesive,  and  while  the  layers  may  be  inter- 
woven to  a  certain  degree,  yet  the  union  thus  formed  cannot  be 
considered  sufficiently  secure  to  hold  the  final  piece  in  place  against 
any  appreciable  wear.  If  the  operator  finds  in  condensing  the  first 
rope  that  it  is  likely  to  carry  the  filling  too  close  to  the  occlusal  sur- 
face, he  should  tear  off  a  piece  and  lay  it  aside  so  as  to  leave  an  ap- 
preciable depth  to  the  cavity  before  adding  the  last  rope.     This  use 


MAXIPULATIOX    OF    TIX    AXD    GOLD.  225 

of  two  or  more  ropes  instead  of  making  a  single  rope  of  sufficient 
size  to  fill  any  of  these  occlusal  cavities  is  advocated  because  of  the 
unwieldy  nature  of  a  rope  which  is  much  greater  than  an  inch  in 
length. 

In  view  of  the  fact  that  it  is  seldom  advisable  to  use  this  ma- 
terial in  cavities  having  a  very  broad  area  presented  to  the  occlusal 
surface,  on  account  of  the  tendency  to  rapid  wear  under  such  con- 
ditions, the  usual  method  of  inserting  the  filling  is  to  wedge  be- 
tween surrounding  walls,  the  limit  of  the  cavity  ordinarily  being 
such  as  to  permit  of  this  plan.  The  rope  should  be  grasped  by 
the  pliers  about  five  or  six  millimeters  from  the  end,  and  this  end 
carried  into  the  cavity  so  as  to  fold  upon  itself  against  the  pulpal 
^vs^\\.  The  rope  should  then  be  grasped  a  little  farther  back  and 
folded  again  into  the  cavity,  this  process  being  kept  up  till  suf- 
ficient of  the  rope  has  been  gathered  into  the  cavity  to  constitute 
an  appreciable  mass  when  condensed  and  permit  of  being  wedged 
between  the  surrounding  walls  of  the  cavity.  If  the  cavity  is  so 
deep  that  it  will  require  more  than  one  rope  to  fill  it,  the  first  rope 
may  be  nearly  all  carried  to  place  with  the  pliers  before  the  plug- 
ger  is  used  to  condense  it,  but  if  only  one  rope  is  required  the  con- 
densation should  begin  after  the  first  half  has  been  forced  into 
place  and  while  the  other  half  is  still  hanging  free  from  the  cavity. 

The  manner  of  condensing  is  by  hand  pressure,  using  a  stiff- 
shanked,  coarsely-serrated  plugger.  This  should  be  forced  toward 
the  pulpal  wall  in  the  middle  of  the  mass  of  material,  and  then 
vigorously  swayed  in  every  direction  to  carry  the  material  snug 
and  tight  against  the  surrounding  walls,  using  as  much  force  in 
these  movements  as  can  safely  be  done  short  of  injury  to  tooth- 
tissue  or  the  peridental  membrane.  The  same  precaution  against 
overmanipulation  is  necessary  here  as  with  the  gingival  portion  of 
proximal  fillings.  When  a  few  vigorous  and  effective  wedging 
movements  have  been  made  against  the  mass,  some  more  of  the 
rope  should  be  gathered  into  position  and  the  wedging  continued. 
As  the  surface  is  approached  the  free  end  of  the  rope  should  be 
folded  over  so  as  to  look  toward  tlie  pulpal  wall,  and  it  should  be 
forcibly  driven  into  the  mass  of  filling-material  and  interwoven 


226  PRINCIPLES    AND    PKACTICE    OF    FILLING    TEETH. 

with  it,  leaving  the  looped  side  of  the  rope  presented  to  the  occlu- 
sal surface.  Care  should  be  taken  to  have  the  material  somewhat 
more  than  flush  with  the  orifice  of  the  cavity,  but  this  surplus 
should  not  be  manipulated  to  any  extent  with  the  plugger  point- 
For  the  surface  condensation  a  large  ball  burnisher  should  be  used, 
and  the  filling  vigorously  burnished  into  the  cavity  and  against  the 
margins  till  the  surface  is  as  hard  as  this  material  will  permit. 

To  dress  the  filling  to  form  and  give  it  an  even  surface  a  fine 
corundum  stone  may  be  used  in  the  engine,  or  in  cases  of  a  very 
small  filling  in  a  deep  depression  between  cusps  where  a  stone  will 
not  reach  a  finishing  bur  may  be  substituted.  In  places  where  the 
sand-paper  disk  may  be  made  to  reach  the  filling  by  forcing  it  to 
place  with  a  ball  burnisher,  this  will  be  found  the  ideal  method  of 
finishing  these  fillings. 

The  use  of  tin  and  gold  in  these  small  occlusal  cavities  in  chil- 
dren's teeth  is  strongly  advocated  in  preference  to  amalgam.  Con- 
trary to  the  prevailing  impression  in  regard  to  the  matter,  it  can 
be  inserted  more  expeditiously  than  amalgam,  and  if  properly 
manipulated  it  is  more  certain  in  its  results.  It  is  less  treacherous 
than  amalgam.  If  it  fails  it  does  so  in  a  manner  at  once  recog- 
nized, while  amalgam  may  appear  perfect  to  the  naked  eye  and 
yet  be  leaking  so  badly  as  to  cause  the  enamel  to  be  undermined  by 
decay  for  a  considerable  area  around  the  deeper  portions  of  the 
filling.  Tin  and  gold  does  not  shrink  or  change  form  as  does 
much  of  the  amalgam  in  use,  and  it  is  accordingly  a  better  protec- 
tion to  the  cavity-walls.  If  an  operator  becomes  expert  in  its 
manipulation  he  will  find  a  large  range  of  usefulness  for  it  in  his 
practice,  and  it  will  not  prove  a  disappointment.  In  using  tin  foil 
for  filling  teeth  the  same  general  plan  of  manipulation  is  indicated 
as  that  just  outlined  for  tin  and  gold. 


MANIPULATION    OF    AMALGAM.  227 

CHAPTER    XII. 

MANIPULATION  OF   AMALGAM. 

It  may  be  considered  scarcely  practicable  to  lay  down  any  in- 
variable rule  in  regard  to  the  percentage  of  mercury  which  must  be 
mixed  with  an  alloy  to  gain  the  best  results  in  an  amalgam.  The 
vast  number  of  alloys  on  the  market  and  the  variable  requirements 
in  the  different  makes  render  the  question  of  percentage  a  difficult 
one.  The  most  that  can  be  done  is  to  suggest  in  a  general  way  the 
manner  of  mixing  the  alloy  with  the  mercury,  and  indicate  as  ac- 
curately as  may  be  the  proper  consistence  or  plasticity  of  the  mass 
to  secure  the  best  results.  While  it  is  a  mooted  question  as  to 
whether  or  not  it  may  be  injurious  to  an  amalgam  to  so  mix  it  that 
an  excess  of  mercury  is  added  and  subsequently  wrung  out  before 
inserting  the  filling,  it  will  be  found  that  practically  under  present 
conditions  the  most  uniform  product  may  be  obtained  in  that  way. 
If  manufacturers  would  put  up  their  alloy  in  small  capsules  with  an 
accompanying  capsule  of  mercury  accurately  weighed  out  in  the 
per  cent,  that  has  been  demonstrated  by  experiment  to  be  the  best 
for  that  particular  alloy,  it  might  be  practicable  to  so  mix  amalgam 
in  office  w'ork  that  there  need  never  be  any  free  mercury  present; 
but  the  fact  that  this  experiment  has  been  tried  by  at  least  one 
manufacturer  and  failed  to  receive  the  support  of  the  profession 
would  seem  to  indicate  that  the  profession  was  not  willing  to  yield 
this  much  homage  to  the  material.  N^either  can  it  be  expected 
that  practitioners  generally  will  ever  be  persuaded  to  take  the 
trouble  to  weigh  out  the  exact  proportions  for  each  filling  in  the 
daily  routine  of  practice,  even  where  it  is  possible  to  ascertain  the 
proper  proportion  for  the  alloy  they  are  using.  It  would  be  the 
ideal  method  if  this  could  be  done,  but  it  may  well  seem  fruitless  to 
advocate  any  method  of  practice  which  the  profession  manifestly 
will  not  follow. 

In  our  teaching  we  must  aim  to  accomplish  the  greatest  good 
to  the  greatest  number,  and  with  the  varying  alloys  on  the  market 
the  surest  way  to  do  this  is  to  give  the  technical  procedure  neces- 


228  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

sarj  to  the  best  preparation  of  the  alloy  for  filling.  With  most  of 
the  alloys  at  present  in  use  by  the  profession  the  amalgamation 
of  the  mass  does  not  seem  to  take  place  so  readily  as  those  in  com- 
mon use  a  dozen  years  ago,  and  the  mass  therefore  requires  more 
extended  mixing  in  order  to  secure  a  perfect  incorporation  of  the 
mercury  with  the  fillings.  To  do  this  it  is  advisable  to  use  a  pestle 
and  mortar  at  least  in  the  early  part  of  the  mixing.  This  mortar 
should  be  of  appreciable  size,  and  the  inner  surface  of  the  bowl 
should  be  roughened.  The  small  smooth  glass  mortars  sometimes 
offered  for  sale  for  mixing  amalgam  are  not  at  all  suited  to  the 
purpose,  there  being  insuflicient  area  for  trituration  and  no  re- 
sistance to  the  gliding  of  the  mass  along  the  inner  surfaces  in  front 
of  the  pestle.  A  roughened  surface  results  in  the  ingredients  be- 
ing caught  between  the  pestle  and  the  mortar  so  that  they  receive 
the  proper  amount  of  grinding. 

Sufficient  mercury  for  the  case  in  hand  should  be  placed  in  the 
mortar,  and  filings  added  little  by  little  as  the  grinding  proceeds, 
until  the  mass  reaches  a  consistence  which  would  seem  to  indicate 
that  if  more  filings  were  added  it  would  interfere  with  the  plastic- 
ity of  the  product  and  render  it  granular.  At  this  point  it  is  well 
to  transfer  the  mass  to  the  palm  of  the  hand  and  knead  it  quite 
vigorously  with  the  ball  of  the  finger  of  the  other  hand.  This 
kneading  will  usually  result  in  increasing  the  plasticity  of  the  mass, 
and  if  it  is  found  that  too  much  mercury  is  apparent  some  more 
filings  should  be  added  and  the  kneading  continued.  The  mass 
should  be  mixed  just  to  the  point  where  there  seems  to  be  a  com- 
plete incorporation  of  the  filings  with  the  mercury  and  where  pres- 
-sure  of  the  mass,  such  as  wringing  vigorously  in  chamois  or  strong 
linen  with  the  fingers,  will  result  in  a  minute  quantity  of  mercury 
being  expressed  from  it.  In  view  of  a  possible  disarrangement 
of  the  formula  of  the  alloy  by  carrying  away  more  of  one  metal 
than  another  in  the  expressed  mercury,  it  is  always  well  to  have 
the  mass  of  such  consistence  that  it  is  possible  to  wring  out  only  a 
very  small  amount.  When  the  mass  is  taken  from  the  linen  it 
should  break  apart  easily  with  little  apparent  plasticity  to  it,  and 
if  the  amalgam  is  of  the  quick-setting  variety  it  should  be  kept 


MANIPULATION    OF    AMALGAM.  229 

under  constant  movement  till  the  last  piece  is  condensed  in  the 
cavity.  That  is,  when  part  of  it  has  been  placed  in  the  cavity  pre- 
paratory to  condensing  it  the  portion  remaining  on  the  operating 
table  should  be  kneaded  by  the  assistant  till  it  is  required,  and  if 
the  operator  has  no  assistant  he  should  manage  in  some  way  with 
the  fingers  of  his  left  hand  to  keep  the  mass  in  motion.  If  he 
finds  this  impracticable  he  would  better  select  a  slower-setting 
alloy. 

Method  of  Packing  Amalgam. 

The  pluggers  used  for  this  purpose  should  be  flat-faced  instead 
of  rounded,  and  should  be  as  large  in  area  as  can  conveniently  be 
employed  in  the  given  cavity.  The  idea  should  always  be  to  carry 
the  mass  in  front  of  the  plugger  directly  against  the  cavity-wall, 
instead  of  having  it  squeeze  out  alongside  the  instrument.  Amal- 
gam should  not  be  treated  as  if  it  were  intrinsically  a  plastic  ma- 
terial and  could  be  patted  to  position  with  little  force.  Amalgam 
to  gain  the  best  results  must  be  condensed  by  heroic  pressure.  If 
too  small  an  instrument  is  used,  a  sufficient  pressure  for  proper 
condensation  will  result  in  the  plugger  piercing  the  mass  and  driv- 
ing the  material  to  either  side  of  it.  The  aim  should  be  to  keep 
the  mass  gathered  before  the  instrument  so  that  it  is  carried  only  in 
the  direction  toward  which  the  force  is  exerted,  and  to  accomplish 
this  a  broad  flat-faced  plugger  is  necessary,  unless  the  area  of  the 
cavity  is  so  small  that  the  amalgam  is  forced  against  the  surround- 
ing walls.  If  a  filling  is  to  be  made  which  is  not  more  or  less 
porous,  the  ingredients  of  the  amalgam  must  receive  vigorous  com- 
pression. Realizing  this,  some  operators  recommend  mallet  force 
to  condense  amalgam,  but  it  would  seem  to  be  immaterial  which 
way  the  force  is  applied,  whether  by  mallet  or  hand  pressure,  so 
long  as  the  compression  is  sufficiently  forceful. 

Recognizing  the  character  of  amalgam,  it  will  readily  be  ap- 
preciated that  to  secure  the  best  results  in  its  insertion  it  is  neces- 
sary to  have  a  cavity  with  surrounding  walls  instead  of  one  with 
an  open  aspect  and  one  wall  missing,  as  in  a  proximo-occlusal  cavity 
in  a  molar.  All  cavities,  therefore,  involving  the  proximo-occlusal 
surfaces  should  be  reinforced  by  a  matrix  to  gain  the  best  results  in 


230  PRINCIPLES    AjSTD    PRACTICE    OF    FILLING    TEETH. 

condensation.  In  cases  of  very  extensive  restoration  where  the 
tooth-tissue  has  been  badly  broken  down,  a  matrix  of  thin  German 
silver  should  be  made  for  the  case  by  wrapping  a  strip  of  the  ma- 
terial around  the  tooth  and  tacking  the  ends  together  with  solder. 
AVhen  this  is  slipped  over  the  tooth  it  can  be  burnished  to  the 
proper  form,  and  after  the  insertion  of  the  filling  the  matrix  may 
be  allowed  to  remain  on  the  tooth  till  the  following  day  as  a  sup- 
jDort  to  the  amalgam  during  the  process  of  crystallization.  At  the 
next  visit  of  the  patient  the  matrix  may  be  cut  and  removed  and 
the  filling  polished. 

The  manner  of  inserting  amalgam  is  to  take  a  small  piece  in  the 
pliers  and  carry  it  to  place  in  the  cavity,  condensing  it  thoroughly 
before  another  piece  is  added.  As  the  filling  is  thus  being  built 
up  piece  by  piece,  if  the  compression  results  in  bringing  surplus 
mercury  to  the  surface  the  soft  mass  thus  resulting  should  be 
scraped  from  the  filling  and  the  next  piece  of  amalgam  added  to 
the  harder  portion  beneath  it.  An  amalgam  filling  cannot  have 
a  satisfactory  surface  with  an  excess  of  mercury  present.  Even 
if  it  did  not  interfere  with  the  integrity  of  the  mass,  there  would 
still  remain  a  physical  reason  why  a  softened  surface  is  contra- 
indicated.  No  operator  can  be  certain  that  he  has  secured  uni- 
form adaptation  to  cavity-walls  in  the  attempt  to  condense  a  soft 
mass  of  amalgam.  This  material  under  those  conditions  acts  rela- 
tively like  a  mass  of  jelly,  so  that  if  the  operator  forces  it  against 
one  margin  it  is  immediately  drawn  away  from  another.  The  only 
possible  way  to  be  assured  of  adaptation  to  all  of  the  outlines  of  a 
cavity  in  the  effort  to  insert  soft  amalgam  would  be  to  have  a  plug- 
ger  point  as  broad  as  the  area  of  the  cavity,  and  bring  force  over 
the  entire  surface  of  the  filling  at  the  same  time.  This,  of  course, 
is  seldom  feasible,  and  it  will  accordingly  be  apparent  that  to  get 
good  results  with  amalgam  and  produce  a  filling  which  does  not 
leak  at  some  point  it  must  be  used  without  an  excess  of  mercury. 

"When  the  filling  is  built  to  the  requisite  fullness  it  should  at 
once  be  trimmed  to  form  before  it  is  allowed  to  become  hard.  The 
occlusal  surface  may  be  smoothed  by  taking  a  pellet  of  tightly 
rolled  cotton  in  the  pliers  and  gently  wiping  it  across  the  surface, 


MANIPULATIOX   OF   CEMEXTS.  231 

always  in  the  direction  of  the  margins.  Any  snrphis  on  the  pr<:)xi- 
uial  surface  in  the  interproximal  space  must  be  carefully  removed 
at  this  sitting'  with  thin  amalgam  trimmers.  If  small  particles  of 
the  material  are  allowed  to  extend  over  the  cavity-margins  at  this 
point  till  crystallization  has  taken  place  it  will  be  found  very  diffi- 
cult to  remove  them,  and  if  they  are  not  removed  and  the  filling 
made  smooth  and  even  with  the  surface  of  the  enamel  the  gum  in 
the  interproximal  space  will  invariably  present  an  abnormal  con- 
dition on  account  of  the  irritation.  It  is  necessary  to  look  as  care- 
fully to  the  finish  of  an  amalgam  filling  at  this  point  as  to  a  gold 
filling,  and  the  trimming  to  form  should  invariably  be  done  while 
the  amalgam  is  still  semi-plastic.  Close  attention  should  also  be 
given  to  the  occlusion,  so  that  an  opposing  cusp  may  not  injure  the 
filling  by  too  great  impact  before  it  is  hard. 

When  the  filling  is  thus  properly  formed  the  case  may  be  dis- 
missed till  another  sitting,  at  which  time  it  should  be  polished  with 
the  same  care  and  in  the  same  manner  as  a  gold  filling.  Amalgam 
will  take  a  most  beautiful  finish,  and  if  inserted  with  painstaking- 
care  along  the  lines  indicated,  and  polished  at  a  subsequent  sitting, 
the  results  in  amalgam  work  will  prove  more  beneficial  and  more 
uniformly  satisfactory  than  we  ordinarily  see  in  the  mouths  of  our 
patients. 


CHAPTER    XIII. 

MANIPULATION  OF  CEMENTS. 

In  the  preparation  of  cement  for  filling  teeth  the  plan  of  mixing 
is  somewhat  important.  A  quantity  of  powder  sufficient  for  the 
case  in  hand  should  be  placed  upon  the  mixing  slab,  and  a  short 
distance  from  this  the  requisite  amount  of  liquid.  The  means 
used  to  dip  the  liquid  from  the  bottle  should  be  such  as  not  to 
contaminate  the  remaining  contents  of  the  bottle.  The  liquid  of 
cement  to  give  the  most  serviceable  working  quality  should  be  of 
a  consistence  bordering  closely  on  crystallization.     In  fact,  a  liquid 


232  PEIIiTCIPLES    AND    PKACTICE    OF    FILLING    TEETH. 

which  presents  no  tendency  to  crystallization  and  which  remains 
permanently  fluid  under  all  circumstances  cannot  be  considered 
the  safest  kind  of  liquid  for  ordinary  use  in  the  mouth.  This 
tendency  in  most  of  the  reliable  fluids  renders  it  necessary  to 
handle  them  with  great  care,  to  avoid  as  largely  as  possible  the 
formation  of  crystals.  Crystals  are  readily  formed  if  small  quan- 
tities of  the  liquid  are  left  exposed  to  the  air,  and  thus  we  find 
about  the  mouths  of  the  bottles  more  or  less  of  a  crystallized  mass, 
on  account  of  leaving  a  surplus  of  the  material  clinging  to  the 
cork  and  smeared  over  the  rim  of  the  bottle.  Small  particles  from 
this  crystallized  mass  dropping  into  the  bottle  from  time  to  time 
tend  to  start  other  centers  of  crystallization  in  the  fluid,  and  the 
entire  contents  of  the  bottle  may  thus  be  contaminated.  In  view 
of  this  it  is  always  desirable  to  keep  the  mouth  of  the  bottle  as  free 
from  the  liquid  as  possible,  and  consequently  the  practice  of  pour- 
ing the  liquid  from  the  bottle  to  the  slab  is  contraindicated.  The 
liquid  should  be  carefully  dipped  out  and  dropped  on  the  slab  by 
some  instrument  which  is  not  in  any  way  acted  on  by  the  liquid. 
The  ordinary  steel  spatulas  are  more  or  less  affected  by  the  acid  in 
the  liquid,  and  should  not  be  used  either  for  dipping  out  the  liquid 
or  mixing  the  cement.  Dr.  W.  V-B.  Ames  suggests  for  this  pur- 
pose a  spatula  made  of  German  silver,  which  is  sufficiently  rigid  for 
a  thorough  trituration  of  the  cement  and  which  is  not  affected  by 
the  liquid.  It  need  not  be  intimated  that  the  spatula  should  never 
be  placed  in  the  liquid  to  dip  an  additional  amount  from  the  bottle 
after  it  has  been  used  to  commence  the  mixing.  If  more  liquid  is 
required,  it  should  be  dipped  -with  a  glass  rod  or  some  non-corrosive 
instrument. 

In  mixing  the  cement  the  powder  should  be  added  to  the  liquid 
little  by  little,  the  mass  meanwhile  being  thoroughly  stirred  and 
rubbed  with  the  spatula.  Most  operators  fail  to  mix  their  cement 
with  sufficient  vigor  to  obtain  a  perfect  incorporation  of  the  powder 
with  the  liquid.  The  best  results  are  gained  by  a  very  vigorous 
rubbing  over  a  considerable  area  of  the  slab, — the  powder  being 
added  till  the  mass  is  almost  as  stiff  as  freshly  prepared  putty.  If 
it  is  to  be  used  for  the  temporary  sealing  of  medicaments  in  a 


MANIPULATION   OF  CEMENTS.  233 

cavity  or  for  any  purpose  where  pressure  cannot  be  used  in  its  in- 
sertion, it  may  be  left  more  plastic  so  as  to  flow  with  little  resist- 
ance, but  if  to  be  used  for  fillings  it  should  be  made  reasonably  stiff 
and  then  forced  into  place  with  considerable  pressure. 

A  convenient  means  of  carrying  the  mass  from  the  spatula  to 
the  cavity  is  to  first  gather  the  cement  into  a  ball  on  the  end  of 
the  spatula,  and  then,  having  some  cotton  rolled  into  a  tight,  com- 
pact pellet,  grasp  this  firmly  with  the  pliers  and  use  it  as  a  means 
of  scraping  the  cement  from  the  spatula  to  the  cavity.  The  cot- 
ton must  be  rolled  tight  to  prevent  the  cement  from  clinging  to  it. 
Some  varieties  of  cements  are  more  adhesive  to  cotton  than  others, 
but  with  most  of  them  if  they  are  mixed  sufficiently  stiff  to  yield 
the  best  results  in  fillings  the  tight  cotton  roll  may  be  used  very  ad- 
vantageously. When  the  cement  has  been  pressed  to  place  in  the 
cavity  with  the  cotton  and  the  excess  wiped  away,  still  further 
compression  may  be  made  with  a  broad,  smooth,  flat-faced  plugger 
just  as  the  mass  begins  to  crystallize,  but  after  crystallization  has 
once  definitely  set  in  the  filling  should  not  be  disturbed  by  manipu- 
lation till  it  has  become  hard.  The  filling  should  be  dressed  to  the 
proper  form  while  it  is  still  soft  by  the  use  of  thin  instruments  of 
a  form  indicated  by  the  requirements  of  the  case,  the  trimming 
always  being  done  toward  the  margins. 

In  using  cement  for  children's  teeth  in  those  incipient  cavities 
in  the  occlusal  surfaces  of  bicuspids  and  molars,  a  most  effective 
means  of  forcing  the  cement  to  place  and  keeping  it  dry  for  a  few 
minutes  after  its  insertion  is  to  carry  the  material  to  the  cavity  in 
the  ordinary  way  and  press  it  into  position  with  the  cotton  pellet, 
leaving  an  excess  heaped  up  over  the  vicinity  of  the  cavity.  On 
this  excess  the  ball  of  the  operator's  finger  should  be  placed,  cover- 
ing the  entire  occlusal  surface  of  the  tooth  and  forcibly  com- 
pressing the  cement  into  position  till  the  surplus  is  squeezed  out 
over  the  marginal  ridges  of  the  occlusal  surface.  The  finger 
should  be  most  vigorously  forced  against  the  tooth  and  held  there 
witli  considerable  compression  till  the  cement  has  begun  to  crystal- 
lize, after  which  the  surface  may  be  smoothed  with  an  instrument. 


234  PEiisrciPLEs  and  practice  of  filling  teeth. 

CHAPTEK   XIY. 

MANIPULATION  OF  GUTTA-PEKCHA. 

The  great  desideratum  in  the  use  of  gutta-percha  is  to  so  regu- 
late the  heat  in  softening  it  that  the  mass  will  be  made  sufficiently 
pliable  to  be  readily  inserted  in  the  cavity  without  in  the  slightest 
degree  overheating  the  material.  If  gutta-percha  is  brought  into 
contact  with  the  flame  it  is  almost  instantly  charred  and  ruined, 
and  should  never  be  introduced  into  a  cavity.  The  most  effective 
means  of  heating  it  is  on  a  warm  porcelain  slab  placed  some  dis- 
tance from  the  flame  so  that  the  heat  is  gradual  and  steady,  but 
if  the  operator  cannot  take  the  time  for  this  he  may  get  satisfactory 
results  by  heating  it  over  a  flame,  provided  he  exercises  sufficient 
caution.  The  pieces  of  gutta-percha  may  be  grasped  in  the  pliers 
and  held  so  far  above  the  flame  that  the  heat  is  not  intense  enough 
to  injure  the  mass,  and  when  sufficiently  warmed  they  may  be  car- 
ried directly  to  the  cavity  and  compressed  to  place.  If  the  ordi- 
nary pink  gutta-percha  base-plate  is  used — and  this  makes  a  more 
permanent  filling  than  any  of  the  white  preparations — there  is 
another  reason  why  the  heating  should  be  carefully  watched. 
This  material  requires  greater  heat  to  render  it  soft  than  most 
other  forms,  and  it  is  therefore  inclined  to  cause  pain  when  ap- 
plied to  a  tooth  with  a  living  pulp,  and  the  slightest  degree  of 
over-heating  adds  seriously  to  the  discomfort.  The  idea  with  any 
gutta-percha  is  to  warm  with  a  low  degree  of  heat  continued  for 
some  time,  the  reason  being  that  the  conductive  properties  of  the 
material  are  poor  and  it  requires  time  to  make  the  mass  uniformly 
soft.  A  rapid  heating  at  high  temperature  simply  sears  the  sur- 
face without  softening  the  entire  piece. 

For  temporary  work  such  as  sealing  medicaments  in  teeth  the 
softer  forms  of  gutta-percha  known  as  the  temporary  stoppings  are 
preferable  to  the  base-plate.  They  are  softened  with  much  less 
heat,  are  readily  molded  to  cavity-walls,  making  perfect  sealing 
agents,  and  are  more  easily  removed.     In  using  them  care  must 


MAKING    INLAY    FILLINGS.  235 

be  exercised  not  to  overheat,  because  of  the  disagreeable  stickiness 
which  too  much  heat  imparts  to  them.  If  gently  heated  they  may 
be  made  soft  at  a  temperature  which  will  permit  of  the  mass  being 
kneaded  between  the  thumb  and  finger  like  putty. 

In  finishing  a  gutta-percha  filling  the  surplus  may  be  trimmed 
away  with  a  heated  instrument,  dressing  always  toward  the  mar- 
gin. If  there  seems  a  tendency  for  the  gutta-percha  to  curl  away 
from  cavity-margins  the  instrument  should  be  made  just  warm 
enough  to  slightly  soften  the  mass,  and  then  the  broad  side  of  it 
should  be  placed  forcibly  against  the  surface  of  the  filling  and  held 
there  with  considerable  compression  till  it  becomes  cool.  The 
gutta-percha  will  then  remain  stationary. 


CHAPTER    XV. 

MAKING  INLAY  FILLINGS. 

The  two  kinds  of  inlays  most  in  use  are  the  porcelain  inlays  for 
exposed  positions  in  the  anterior  teeth,  and  gold  inlays  in  bicuspids 
and  molars  where  the  stress  of  mastication  is  an  important  con- 
sideration. An  inlay  is  made  by  first  fitting  a  thin  metal  matrix 
to  the  cavity,  and  then  flowing  into  this  the  inlay  material  to  the 
required  contour  and  cementing  it  into  position  in  the  tooth. 

Porcelain  Inlays. 

The  demand  for  porcelain  inlays  sprang  from  the  indiscriminate 
and  inartistic  display  of  gold  in  tlie  anterior  part  of  the  mouth, 
whereby  the  esthetic  sense  of  the  people  has  been  too  frequently 
offended.  If  the  profession  had  more  carefully  studied  the  possi- 
bilities of  platinum  and  gold  for  harmonizing  shades  on  exposed 
surfaces,  there  never  would  have  developed  the  reflection  upon 
dental  art  that  has  been  justly  urged  against  it,  but  it  still  remains 
true  that  there  are  certain  cavities  in  which  a  well-made  porcelain 
inlay  is  more  artistic  in  appearance  than  it  is  possible  to  attain  with 
any  metal  filling.     It  is  also  true  that  inlay  work  is  less  exhausting 


236  PRiisrciPLES  and  practice  of  filling  teeth. 

to  the  patient  than  extensive  filling-building,  and  these  two  con- 
siderations should  induce  every  operator  to  so  perfect  himself  in 
inlay  work  that  he  is  enabled  to  give  his  patients  the  benefit  of  the 
highest  class  of  skill  in  those  cases  where  inlays  are  indicated. 

The  chief  indications  for  inlays  in  the  anterior  teeth  relate  to 
cavities  with  an  open  aspect  presented  to  the  labial.  These  may 
occur  occasionally  in  the  labio-proximal  region,  giving  a  broad 
labial  exposure  with  a  strong  lingual  wall  still  standing,  but  the 
most  frequent  demand  for  inlays  is  in  those  cavities  occurring 
in  the  labial  surface  near  the  gum.  The  preparation  of  the  cavity 
for  an  inlay  involves  the  thorough  opening  up  of  the  cavity  so 
that  no  overhanging  walls  are  left.  The  orifice  must  manifestly 
be  broader  than  the  interior,  else  the  inlay  if  accurately  fitted  will 
not  pass  to  place,  but  on  the  other  hand  the  cavity  must  not  be 
Fig.  97.  left  too  shallow  or  too  much  saucer-shaped  on  account  of 
the  diificulty  of  maintaining  an  inlay  in  position  in  a 
cavity  so  formed.  The  marginal  outline  should  be  made 
symmetrical  and  artistic,  but  the  enamel  for  a  porcelain 
inlay  should  not  be  so  extensively  beveled  as  to  necessi- 
tate a  thin  edge  to  the  porcelain.  If  possible  the  sur- 
rounding walls  of  the  cavity  should  flare  out  very  gently  as  they 
approach  the  enamel-surface,  thus  readily  admitting  the  inlay  to 
place,  and  protecting  the  enamel  without  creating  an  attenuated 
and  friable  edge  to  the  inlay.     (Fig.  97.) 

When  the  cavity  is  prepared  a  piece  of  platinum  foil,  about  ISTo. 
60,  and  somewhat  larger  in  area  than  the  orifice  of  the  cavity, 
should  be  thoroughly  annealed  and  placed  over  the  cavity.  A 
tightly  rolled  pellet  of  cotton  grasped  in  strong-pointed  pliers 
should  be  used  as  the  first  medium  of  compression  to  partially  carry 
the  platinum  matrix  to  place.  When  the  platinum  has  been 
forced  sufiiciently  into  the  cavity  to  curl  up  and  fold  over  itself 
along  the  margins,  it  should  be  withdrawn  from  the  cavity  and  the 
folds  carefully  straightened  out  with  pliers.  This  should  be  done 
frequently  during  the  process  of  fitting  the  matrix,  to  avoid  as 
largely  as  possible  the  overlapping  of  the  platinum  around  the 
margins.     When  the  cotton  pellet  is  no  longer  effective  with  the 


MAKING    INLAY    FILLINGS.  237 

pliei-s,  a  round-headed  burnisher  may  be  used  to  still  further  drive 
the  cotton  into  the  matrix.  The  advantage  of  cotton  is  that  the 
matrix  is  thereby  seldom  torn  in  the  early  part  of  the  fitting. 
When  the  cotton  has  done  its  utmost  limit  of  work,  a  burnisher 
may  be  used  to  bring  about  a  closer  adaptation  to  the  cavity  by 
holding  the  matrix  with  a  retaining  instrument  against  one  side 
of  the  cavity  while  the  burnishing  proceeds  against  the  opposite 
side.  Care  should  be  exercised  not  to  tear  the  platinum  during 
the  burnishing,  but  usually  if  a  tear  does  occur  it  is  in  the  deeper 
parts  of  the  cavity,  and  can  be  remedied  by  burnishing  a  fresh 
piece  of  platinum  over  the  break  before  the  matrix  is  removed  for 
the  last  time. 

In  using  the  burnisher  the  operator  will  find  a  decided  tendency 
for  the  platinum  to  be  drawn  away  from  one  part  of  the  cavity 
while  it  is  being  forced  against  another.  To  overcome  this  and 
also  to  secure  the  closest  possible  accuracy  of  adaptation  to  the 
entire  cavity  the  final  fitting  should  be  done  by  placing  a  mass  of 
unvulcanized  rubber  into  the  matrix — more  than  sufiicient  to  fill 
the  cavity — and  with  a  broad-ended  instrument  forcing  the  rubber 
down  into  the  matrix  and  driving  it  vigorously  w^ith  a  rocking  mo- 
tion of  the  instrument  into  the  remotest  parts  of  the  cavity.  A 
very  accurate  fitting  of  the  platinum  can  thus  be  obtained  if  the 
rubber  is  properly  manipulated.  When  the  rubber  is  removed, 
the  matrix  should  be  carefully  lifted  from  the  cavity  and  the  sur- 
plus platinum  overlying  the  enamel-surface  trimmed  away.  In 
lifting  the  matrix  from  the  cavity  there  is  always  more  or  less  dan- 
ger of  warping  it  slightly  or  in  some  manner  getting  it  out  of  form, 
and  to  avoid  this  it  should  be  placed  back  in  the  cavity  after  the 
trimming  and  packed  full  of  temporary  stopping  before  it  is  re- 
moved for  the  last  time.  When  the  gutta-percha  becomes  hard  the 
matrix  may  then  be  removed  without  change  of  form,  and  the 
stopping  can  be  picked  out  without  disturbing  the  matrix  by  first 
heating  it  very  gently.  During  the  entire  process  of  fitting  the 
platinum  to  the  cavity  it  should  be  frequently  annealed  to  keep  it 
soft  and  workable. 

The  matrix  is  now  ready  for  the  reception  of  the  porcelain,  and 


238  PEII^CIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

if  the  details  have  been  carefully  carried  out  the  result  is  a  matrix 
which  fits  the  cavity  so  as  to  leave  the  smallest  possible  interstice 
for  the  cementing  material  to  occupy. 

The  question  of  the  most  suitable  body  for  use  in  porcelain  in- 
lays has  been  quite  extensively  discussed  by  the  profession,  and 
there  seems  to  be  much  diversity  of  opinion  as  to  whether  a  low- 
fusing  or  a  high-fusing  body  is  indicated.  While  every  practi- 
tioner is  justly  entitled  to  his  own  individual  opinion  in  the  matter, 
it  may  safely  be  stated  on  general  principles  that  if  an  operator 
wishes  invariably  to  give  his  patients  the  best  class  of  service  he 
can  do  so  only  by  the  use  of  the  higher-fusing  bodies.  The  low- 
fusing  bodies  (those  used  in  a  matrix  of  gold)  are  too  nearly  akin  to 
glass — or  at  least  are  too  readily  rendered  glass-like  in  character  by 
the  slightest  overheating — to  make  them  reliable  for  such  delicate 
work  as  inlays.  The  problem  of  shades  is  a  most  important  one  in 
inlays,  and  shading  is  never  so  certain  with  the  low-fusing  bodies 
as  with  the  higher. 

The  counter-consideration  may  be  urged  that  the  high-fusing 
bodies  are  more  exacting  in  regard  to  the  length  of  time  and  the 
degree  of  heat  required  for  fusing,  and  also  that  the  operator  is 
limited  to  the  one  metal,  platinum,  for  the  matrix,  whereas  with  a 
sufiiciently  low-fusing  body  pure  gold  may  be  used  to  greater  ad- 
vantage on  account  of  being  more  readily  adapted  to  the  cavity. 
These  considerations  should  have  very  little  weight  with  a  con- 
scientious operator  who  aims  only  to  give  his  patient  the  benefit 
of  the  highest  perfection  in  his  art.  If  a  porcelain  inlay  is  indi- 
cated at  all  the  very  best  possible  inlay  is  none  too  good,  and  unless 
an  operator  is  willing  to  give  to  this  work  the  same  painstaking  care 
that  he  does  to  other  intricate  and  delicate  operations  he  would 
better  dispense  with  it  entirely.  It  is  here  predicted  that  much 
of  the  hasty-pudding  porcelain  inlay  work  now  being  done  by  the 
profession  will  result  in  bringing  discredit  on  the  reputation  of 
dentistry,  and  it  will  not  be  the  first  instance  where  the  public 
and  the  profession  have  suffered  from  the  universal  clamoring 
after  an  easy  way  of  doing  things. 

Before  an  operator  attempts  porcelain  inlay  work  he  should 


MAKING    INLAY    FILLINGS.  239 

make  himself  familiar  with  the  management  of  high-fusing  bodies 
both  in  relation  to  the  method  of  baking  and  the  control  of  shades, 
and  tl>is  can  only  be  attained  by  actual  experimentation  with  the 
material  itself.  It  is  without  the  province  of  this  book  to  go  more 
minutely  into  the  subject  of  porcelain,  except  to  say  that  for  inlays 
a  finer-grained  product  and  an  altogether  more  perfect  porcelain 
is  required  than  for  any  other  kind  of  work  in  the  mouth., 

AVhen  the  inlay  is  baked  the  platinum  matrix  should  be  peeled 
away,  leaving  the  porcelain  ready  for  setting.  If  the  form  of  the 
cavity  is  such  that  the  retention  of  the  inlay  is  in  doubt,  the  former 
may  be  undercut  with  a  bur  or  excavator  and  the  cavity  side  of  the 
inlay  grooved  with  a  thin  disk.  In  setting  the  inlay  the  cavity 
should  be  dry  and  the  cement  carefully  mixed  to  such  a  consistence 
that  it  will  require  some  force  to  squeeze  it  out  from  under  the  in- 
lay, but  it  should  not  be  so  stiff  that  the  inlay  cannot  be  driven  per- 
fectly in  place.  In  forcing  the  inlay  a  wooden  point  may  be  used, 
and  considerable  pressure  should  be  maintained  on  the  inlay  for 
several  minutes  till  the  cement  begins  to  crystallize,  after  which 
the  surplus  may  be  trimmed  away  and  the  margins  wiped  clean 

with  cotton. 

Gold  Inlays. 

There  is  really  a  wide  range  of  usefulness  for  this  kind  of  inlay 
in  those  cases — already  indicated — where  the  extent  of  the  decay 
ha.s  been  so  great  that  a  gold  filling  is  contraindicated  on  account 
of  the  nervous  tax  on  the  patient.  The  entire  operation  is  much 
less  exhausting  than  filling,  and  while  the  results  can  never  be 
considered  so  permanent  as  with  a  well-inserted  foil  filling,  yet  if 
the  cases  are  selected  with  discriminating  judgment  and  the  opera- 
tion performed  with  painstaking  care  the  practice  is  justifiable  in 
many  instances. 

The  preparation  of  the  cavity  must  be  along  the  same  lines  as 
for  porcelain  inlays,  except  that  the  question  of  anchorage  is  more 
important,  and  in  proximo-occlusal  cavities  the  occlusal  step 
method  should  be  followed  wherever  available.  A  gold  inlay 
locked  into  a  step  at  right  angles  with  the  proximal  portion  of  the 
cavity  is  peculiarly  calculated  to  remain  secure  against  dislodg- 


240  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

ment.  Another  distinction  in  the  preparation  of  cavities  for  gold 
inlays  relates  to  the  treatment  of  enamel-margins.  With  gold  in- 
lay work  the  margins  should  be  very  freely  beveled  and  the  edges 
of  the  inlay  carried  well  over  them.  This  is  one  of  the  most  ser-. 
viceable  features  of  gold  inlays,  that  all  thin  or  frail  enamel  walls 
may  be  dressed  down  and  the  inlay  so  built  over  them  as  to  per- 
fectly protect  them.  In  contradistinction  to  porcelain  inlays,  the 
edges  of  gold  inlays  are  very  strong  and  capable  of  protecting 
.  weak  enamel.  This  overlapping  of  the  cavity-margin  by  the  in- 
lay would  also  seem  to  largely  do  away  with  the  tendency  for  the 
cement  to  dissolve  out  to  any  appreciable  distance  under  the  inlay. 
The  matrix  for  gold  inlays  may  be  made  from  pure  gold,  which 
is  more  readily  adapted  to  the  cavity  than  platinum.  A  con- 
venient thickness  for  this  purpose  is  found  in  one  of  the  heavier 
forms  of  rolled  gold  used  for  finishing  fillings,  such  as  the  No.  60. 
The  same  general  plan  of  fitting  the  matrix  is  followed  as  with 
platinum,  except  that  in  a  proximo-occlusal  cavity  the  gutta-percha 
when  packed  into  the  matrix  previous  to  its  final  removal  should  be 
built  out  into  perfect  contact  with  the  proximating  tooth  and 
trimmed  to  the  exact  form  required  of  the  inlay.  The  same  care 
in  inlay  work  should  be  exercised  with  relation  to  contour  and 
contact  that  has  already  been  advocated  for  an  ordinary  filling, 
and  this  shaping  of  the  gutta-percha  is  preparatory  to  this  end. 
When  the  gutta-percha  and  matrix  have  been  removed  from  the 
cavity  an  investment  should  be  made  in  soldering  plaster  so  as  to 
include  the  cavity  side  of  the  matrix,  and  pass  around  over  the 
gutta-percha  to  assume  the  position  of  the  proximating  tooth. 
The  removal  of  the  gutta-percha  after  the  plaster  has  become  hard 
will  leave  a  form  to  the  plaster  which  indicates  the  required  con- 
tour of  the  inlay.  In  case  the  matrix  has  been  torn  at  any  point 
a  pellet  of  gold  foil  should  be  pressed  gently  over  the  ruptured 
place,  and  the  solder  on  soaking  into  this  will  effectively  repair  the 
breach.  A  high-grade  solder — about  20  carat — should  be  used  to 
fill  the  matrix.  The  piece  should  be  gently  heated  up  to  prevent 
the  formation  of  steam  under  the  matrix  and  its  consequent  dis- 
placement.    In  flowing  the  solder  into  the  matrix  it  should  be 


rULP-CAPPING.  ■    24rl 

built  out  to  the  form  left  in  the  plaster  by  the  gutta-percha,  which 
will  result  in  a  good  contour,  and  the  possibility  of  making  a  per- 
fect contact  point  when  the  inlay  is  dressed  to  the  proper  form  and 
polished. 

In  fitting  the  inlay  to  place  before  cementing  it,  attention  should 
be  given  to  the  occlusion  of  the  opposing  tooth,  and  the  inlay  so 
ground  that  it  will  not  require  further  attention  in  this  respect 
when  cemented.  In  driving  the  inlay  to  position  into  the  cement 
a  plugger  and  mallet  may  be  used,  and  the  inlay  held  firm  till 
crystallization  has  commenced  in  the  cement.  After  this  has 
taken  place  if  there  is  any  unevenness  along  the  junction  of  the 
inlay'  and  enamel  it  may  be  ground  smooth  and  even,  and  then 
polished  with  a  sand-paper  disk.  A  well-fitted  gold  inlay  so  in- 
serted may  often  be  mistaken  for  a  beautiful  gold  filling,  and  this 
may  l^e  said  to  involve  the  highest  excellence  in  gold  inlays. 


CHAPTEK    XVI. 

PULr-CAPPING. 


Whex  decay  has  penetrated  a  tooth  sufliciently  to  reach  the 
pulp,  the  problem  arises  as  to  whether  an  attempt  shall  be  made 
to  save  the  pulp  by  capping  or  whether  it  shall  be  destroyed  and  the 
canal  filled.  The  question  is  one  which  calls  for  discriminating 
judgment  on  the  part  of  the  operator  and  a  careful  study  of  the  pe- 
culiar manifestations  presented  in  the  individual  case.  No  set  rule 
can  be  formulated  as  a  guide  under  all  conditions,  but  the  most 
prominent  indications  for  or  against  pulp-capping  may  be  pointed 
out  in  the  way  of  suggestion  to  the  observant  operator. 

The  chief  considerations  relate  to  the  age  of  the  patient,  the  ex- 
tent of  exposure,  the  location  in  the  mouth  of  the  affected  tooth, 
and  the  duration  and  degree  of  the  pain  caused  by  the  exposure. 
In  young  patients  the  prospect  of  saving  a  pulp  alive  is  greater 
thfin  in  aged  patients,  and  the  necessity  is  also  more  urgent.   A  pulp 

ifi 


242  PRiisrciPLEs  and  practice  op  pilling  teeth. 

is  never  through  with  its  active  functional  duty  till  the  tooth  is 
completely  calcified  to  the  very  apex  of  the  root,  and  this  does  not 
take  place  till  after  the  eruption  of  the  crown  through  the  gum. 
In  fact,  teeth  may  erupt  and  take  on  the  carious  process  to  the  ex- 
tent of  pulp-exposure  before  the  apex  of  the  root  is  formed,  and 
if  there  is  death  of  the  pulp  at  this  stage  the  apex  is  left  unformed. 
It  becomes  important,  then,  in  all  cases  of  pulp-exposure  in  young 
patients  to  attempt  to  save  the  pulp  till  the  process  of  calcification 
is  complete,  and  while  teeth  may  vary  in  different  mouths  in  regard 
to  the  age  of  complete  calcification,  it  may  be  said  in  a  general  way 
to  be  about  six  years  after  they  begin  to  erupt.  The  fact  that 
pulps  may  more  successfully  be  saved  during  youth  is  another 
argument  in  favor  of  making  the  attempt,  the  reason  for  this  be- 
ing that  the  apical  openings  in  the  roots  are  larger,  which  gives 
greater  play  for  the  engorgement  of  the  vessels  of  the  pulp  without 
injury.  As  age  advances  the  apical  openings  become  smaller,  and 
a  very  slight  irritation  of  the  pulp  may  cause  its  death. 

The  extent  of  the  exposure  is  also  an  important  factor.  If 
the  pulp  is  only  slightly  exposed  and  has  not  been  injured  in  any 
way,  or  if  it  has  been  accidentally  uncovered  by  an  excavator,  the 
chances  of  saving  it  are  greater  than  where  the  exposure  is  large 
and  the  pulp  thereby  subjected  to  all  the  dangers  of  infection. 
One  of  the  chief  elements  of  success  in  pulp-capping  relates  to  the 
avoidance  of  pressure  on  the  pulp,  and  in  large  exposures  this  is 
more  difficult. 

The  question  of  location  in  the  mouth  refers  to  teeth  that  are 
exposed  to  view  in  contradistinction  to  teeth  so  situated  that  they 
are  never  seen  in  ordinary  conversation, — the  difference  being  that 
Avith  the  former  a  greater  effort  should  be  made  to  save  the  pulp 
than  with  the  latter.  The  reason  for  this  is  that  on  death  of  the 
pulp  there  is  usually  a  tendency  for  the  tooth  to  become  more  or 
less  discolored  and  lose  its  normal  translucency — sometimes  to  the 
extent  of  being  unsightly  and  conspicuous.  The  fact  that  by 
proper  management  from  the  time  the  pulp  is  destroyed  to  the 
final  filling  of  the  cavity  any  serious  discoloration  may  ordinarily 
be  avoided  does  not  alter  the  general  proposition  that  the  most 


PULP-CAPPI]!fG.  243 

conservative  practice  involves  the  saving  of  pulps  in  such  teeth  if 
possible.  An  operator  is  never  able  to  predict  with  certainty  that 
a  pulpless  tooth  will  permanently  retain  its  color  even  under  the 
best  treatment,  and  it  may  therefore  be  considered  a  legitimate 
procedure  to  make  the  attempt  at  pulp-preservation  in  many  of 
these  cases  even  where  the  chances  are  against  it.  There  is  a  wide 
variation  in  the  tenacity  of  life  exhibited  in  different  pulps,  and 
if  there  is  a  reasonable  promise  that  the  pulp  may  be  saved  in 
one  of  the  anterior  teeth  it  should  be  given  the  benefit  of  the 
doubt  and  treated  accordingly.  But  the  operator  should  invari- 
ably protect  his  reputation  by  a  straightforward  statement  of  the 
facts  in  the  case  to  the  patient,  and  a  plain  disavowal  in  advance 
of  any  responsibility  in  the  event  of  the  pulp  dying  under  the 
capping.  If  patients  are  at  all  intelligent  they  will  appreciate 
an  operator's  efforts  on  their  behalf,  and  will  not  hold  him  blame- 
worthy if  the  issue  turns  out  amiss.  AVith  patients  who  are  not 
reasonably  disposed  the  operator  would  better  take  no  chances,  but 
proceed  to  destroy  all  pulps  where  there  is  doubt  of  their  preserva- 
tion. Patients  of  this  type  are  not  entitled  to  the  same  consid- 
eration in  this  particular  that  are  those  with  a  due  regard  for  the 
necessary  limitations  of  human  nature  on  the  part  of  the  dentist, 
and  who  are  charitably  inclined  in  the  face  of  seemingly  unfavor- 
able results. 

A  most  important  consideration  bearing  on  the  decision  as  be- 
tween capping  and  destruction  of  the  pulp  relates  to  the  length  of 
time  the  pulp  has  been  inflamed,  and  the  degree  of  the  inflam- 
matory process.  The  most  apparent  index  to  this  is  the  concur- 
rent pain.  If  a  tooth  has  ached  violently  from  an  exposed,  or 
nearly  exposed,  pulp,  and  particularly  if  this  high  degree  of  in- 
flammation has  continued  for  many  hours,  the  conclusions  are 
that  the  pulp  has  l)een  so  profoundly  affected  that  it  cannot  re- 
cover, and  the  attempt  to  save  it  will  be  fruitless.  But  if  the  pulp 
has  been  l)rought  under  treatment  in  the  early  stages  of  the  in- 
flammatory process,  and  especially  if  it  yields  promptly  to  pallia 
live  treatment,  the  promise  is  greater  tliat  it  may  be  saved 

The  question  of  the  general  health  of  the  j)atioiit  must  not  l)e 


244  PRINCIPLES    AND    PKACTICE    OF    FILLING    TEETH. 

overlooked  in  relation  to  its  bearing  on  the  probable  success  or 
failure  of  pulp-capping,  nor  must  we  lose  sight  of  the  influence 
of  locality.  In  some  regions — ^particularly  in  malarial  districts — 
the  attempt  to  save  exposed  pulps  is  said  to  invariably  result  in 
failure.  Repeated  experiences  of  this  nature  have  often  led  men 
who  were  ordinarily  careful  and  conservative  to  make  the  state- 
ment that  wherever  a  pulp  becomes  actually  exposed  the  only 
legitimate  line  of  treatment  is  to  proceed  to  its  destruction,  but 
in  view  of  the  well-established  fact  that  pulps  have  lived  to  do- 
good  service  for  many  year-s  after  being  capped,  this  must  be  con- 
sidered extreme  teaching.  The  pulp  is  too  useful  under  certain 
conditions — which  have  already  been  indicated — to  justify  an 
operator  in  following  so  radical  a  procedure. 

Pulp-capping,  like  many  other  lines  of  practice,  must  be  studied 
with  care  and  entered  into  with  discriminating  judgment.  The 
operator  must  not  expect  success  in  every  case,  even  among  those 
which  seem  most  favorable,  but  the  fact  that  he  has  failures  should 
not  deter  him  from  an  honest  effort  to  do  the  utmost  limit  for  his, 
patient  in  those  cases  where  the  preservation  of  the  pulp  seems 

desirable. 

Materials  for  Capping  Pulps. 

Various  materials  have  been  suggested  for  capping  pulps,  each 
advocate  claiming  for  his  especial  material  peculiar  virtues  not 
found  in  the  others.  The  fact  that  one  operator  will  use  a  certain 
material  with  a  greater  degree  of  success  than  another,  while  the 
second  will  employ  a  different  material  to  greater  advantage  than 
the  first,  is  only  another  illustration  of  the  ever-present  factor  of 
personal  equation.  We  cannot  eliminate  this  factor  from  con- 
sideration in  any  line  of  practice,  and  in  the  capping  of  pulps  that 
method  and  that  material  which  proves  most  successful  in  the 
hands  of  a  given  operator  should  be  the  method  and  material  for 
him  to  adhere  to. 

And  yet  it  may  be  well  to  consider  in  brief  some  of  the  various 
materials  most  commonly  advocated  for  this  purpose.  The  chief 
requisite  of  an  ideal  material  would  seem  to  be  the  ability  to  pro- 
tect the  pulp  against  external  irritation.     It  should  therefore  be  a 


PULP-CAPPING.  245 

poor  conductor  of  thermal  changes,  and  should  in  itself  be  a  non- 
irritant,  and  plastic  in  nature,  so  that  when  applied  to  the  pulp 
adaptation  without  pressure  may  be  attained,  the  mass  subse- 
quently crystallizing  into  a  rigid  covering  to  the  pulp  to  pro- 
tect it  against  external  impact. 

Gutta-percha  has  sometimes  been  advocated  as  a  pulp-capping. 
It  has  the  advantage  of  being  a  perfect  non-conductor,  and  it  is 
also  non-irritating  in  character,  but  the  very  nature  of  the  ma- 
terial is  such  that  it  cannot  well  be  accurately  adapted  to  an  ex- 
posed pulp  without  the  danger  of  causing  pressure.  [N'either  can 
it  be  depended  on  to  remain  of  uniform  bulk  after  insertion,  and 
the  slight  expansion  which  often  takes  place  in  gutta-percha  may 
act  as  a  mechanical  irritant  to  the  pulp.  It  is  therefore  seldom 
indicated  for  this  purpose, — the  factor  of  pressure  being  a  very 
serious  one  to  consider  in  connection  with  pulp-capping. 

To  avoid  undue  pressure  some  operators  employ  a  thin  concave 
metal  disk,  placing  the  disk  over  the  pulp  with  its  concavity 
toward  the  pulp  and  the  rim  of  the  disk  resting  on  the  dentine 
around  the  point  of  exposure,  and  then  flowing  cement  over  this. 
A  limitation  to  this  plan  would  seem  to  be  the  space  left  between 
the  disk  and  the  pulp.  ISTature's  proverbial  abhorrence  of  a 
vacuum  cannot  be  excluded  from  consideration  in  this  operation, 
and  the  aim  should  invariably  be — adaptation  without  pressure. 

The  oxychloride  of  zinc  has  also  been  advocated  as  a  pulp-cap- 
ping, but  its  strong  irritating  properties  would  seem  to  limit  its  use 
to  those  pulps  which  will  tolerate  a  high  degree  of  irritation  without 
dying  imder  it.  Some  pulps  are  apparently  able  to  live  under 
severe  irritation  and  are  thereby  stimulated  to  throw  out  a  deposit 
of  secondary  dentine  to  protect  themselves,  but  most  pulps  if  sub- 
jected directly  to  the  irritating  influence  of  oxychloride  of  zinc 
will  probably  die  as  the  result.  The  fact  that  the  operator  cannot 
predict  with  any  degree  of  assurance  just  which  pulps  will  stand 
irritation  and  which  will  not,  renders  the  use  of  oxychloride  a 
rather  hazardous  practice. 

The  oxyphosphate  of  zinc  has  probably  claimed  more  advocates 
than  any  other  one  material,  it  being  less  irritating  than  the  oxy- 


246  PRINCIPLES    AJS^D    PRACTICE    OF    FILLING    TEETH. 

chloride  and  very  convenient  to  use.  It  can  be  flowed  over  an  ex- 
posed pulp  so  as  to  gain  adaptation  without  pressure,  and  it  be- 
comes sufficiently  hard  to  adequately  protect  the  pulp  from  ex- 
ternal force.  But  even  the  oxyphosphate  is  somewhat  irritating, — 
so  much  so  to  some  pulps  that  it  is  doubtful  practice  to  place  the 
material  in  direct  contact  with  an  exposure.  To  overcome  this  irri- 
tating action  a  most  excellent  plan  is  to  first  make  a  paste  by  mix- 
ing the  powder  of  the  cement  with  some  oil  of  cloves  and  place  a 
thin  layer  of  this  over  the  point  of  exposure  before  inserting  the 
oxyphosphate.  This  paste  will  effectually  protect  the  pulp  from 
the  irritating  influence  of  the  cement,  and  it  is  also  anodyne  in  its 
action  and  a  good  antiseptic.  This  combination  of  materials  if 
skillfully  employed  will  probably  save  any  pulp  that  can  be  saved, 
and  it  ^^dll  prove  of  great  comfort  to  the  patient  from  the  fact 
that  it  may  be  employed  without  causing  the  slightest  pain.  In- 
stead of  the  oil  of  cloves  paste  some  operators  use  a  solution  of 
gutta-percha  dissolved  in  chloroform  to  form  a  film  over  the  pulp 
before  applying  the  oxyphosphate  of  zinc,  but  most  pulps  do  not 
take  so  kindly  to  this  as  to  the  paste. 

Method  of  Capping  Pulps. 

The  first  requisite  of  success  is  to  remove  all  deleterious  matter 
in  the  immediate  neighborhood  of  the  pulp  by  excavating  the  de- 
calcified and  infected  dentine  as  completely  as  may  be  short  of 
wounding  the  pulp.  The  less  of  this  infiltrated  mass  that  is  left 
in  the  cavity  the  less  the  danger  of  pulp-infection,  as  already 
pointed  out  in  a  previous  chapter.  The  fluids  of  the  mouth  should 
be  carefully  excluded  from  the  cavity  during  the  cleaning  and 
subsequent  capping,  and  nothing  allowed  to  enter  except  what  the 
operator  places  there  himself.  The  cavity  should  first  be  flooded 
with  a  non-irritating  antiseptic,  preferably  the  oil  of  cloves,  and 
after  wiping  out  the  surplus  mth  absorbent  cotton  the  layers  of  de- 
calcified dentine  may  be  peeled  off  with  a  sharp  spoon  excavator. 
When  the  cleaning  is  complete  the  cavity  should  again  be  flooded 
with  the  antiseptic  and  allowed  to  remain  three  or  four  minutes 
while  the  capping  material  is  being  prepared.     ^\n^ien  the  paste 


DESTRUCTION    OF    THE    TULP.  247 

is  ready  the  surplus  antiseptic  should  be  removed  from  the  cavity 
with  absorbent  cotton  and  the  paste  carried  to  position  over  the 
pulp.  This  may  be  done  most  expeditiously  with  a  small  pellet  of 
tightly  rolled  cotton  in  the  pliers.  As  soon  as  the  paste  is  gently 
patted  to  place  and  the  surplus  removed,  the  oxyphosphate  of  zinc 
may  be  carried  to  position  over  it  and  allowed  to  become  hard.  If 
it  is  a  case  where  there  seems  much  doubt  about  the  final  saving  of 
the  pulp,  it  is  well  not  to  subject  the  tooth  at  this  time  to  the  mal- 
leting  of  a  gold  filling.  The  entire  cavity  may  be  filled  with  the 
oxyphosphate  of  zinc  and  the  case  dismissed  for  six  months.  If 
at  the  end  of  that  time  the  pulp  is  found  alive  and  has  given  no 
troulde  a  portion  of  the  cement  filling  may  be  removed  and  re- 
placed by  gold,  leaving  sufficient  of  the  oxyphosphate  over  the 
pulp  to  protect  it. 


CHAPTER    XVIL 

DESTRUCTION  OF  THE  PULP. 

In  case  it  is  deemed  inexpedient  to  attempt  to  save  a  pulp,  the 
necessity  devolves  upon  the  operator  of  destroying  it  and  filling 
the  canal.  The  most  common  method  of  killing  a  pulp  is  to  make 
an  application  of  arsenic  to  it.  This  may  be  used  in  the  form  of 
an  arsenical  paste  prepared  especially  for  the  purpose  by  manu- 
facturers, to  be  sealed  in  the  cavity  for  a  longer  or  shorter  length 
of  time  as  the  circuinstances  indicate^  Another  method  of  ]nilp- 
destruction  relates  to  forcing  a  solution  of  cocaine  into  the  pulp 
either  ])y  cataphoresis,  by  injection,  or  by  pressure,  and  removing 
the  pulp  at  the  same  sitting. 

Tlif  choice  of  methods  must  be  governed  l)y  the  necessities  of 
the  case  in  hand,  and  also  by  the  relative  success  which  each  ope- 
rator may  experience  with  the  different  methods.  Some  operators 
chiim  a  vastly  greater  success  with  ])rcssui'e  anesthesia  than  with 
arsenic,  while  others  do  not  find  it  in  the  h-ast  satisfactory.  In  a 
general  way  it  may  be  suggested  that  wh(!i-over  the  operator  is  not 


248  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

pressed  for  time  in  the  removal  of  the  pulp,  he  will  obtain  more 
uniformly  satisfactory  results  from  arsenic  than  from  cocaine, 
while  in  an  emergency  case  where  the  immediate  removal  of  the 
pulp  is  imperative,  he  will  do  well  to  employ  cocaine. 

Destroying  the  Pulp  with  Arsenic. 

The  prime  requisite  in  the  application  of  arsenic  to  a  pulp  is 
to  bring  it  in  immediate  contact  with  the  pulp  without  exerting 
the  slightest  undue  pressure  upon  it,  and  then  sealing  it  so  se- 
curely in  the  cavity  that  it  cannot  by  any  means  ooze  out  and  come 
in  contact  with  the  gums.  Arsenic  is  exceedingly  destructive  to 
the  tissues,  and  if  it  reaches  the  gums  or  other  soft  parts  it  will  de- 
stroy them  over  a  greater  or  less  area,  dependent  upon  the  amount 
of  arsenic  and  the  length  of  time  it  is  allowed  to  come  in  contact 
with  them,  often  implicating  the  alveolar  process  in  the  destruc- 
tion. This  necessitates  the  most  careful  sealing  of  the  agent  in 
the  cavity,  and  to  accomplish  this  without  causing  pressure  upon 
the  pulp  is  often  a  delicate  procedure.  Much  of  the  pain  in  pulp- 
destruction  that  has  been  laid  at  the  door  of  arsenic  is  probably 
due  to  pressure  in  its  application. 

The  two  materials  most  effective  in  sealing  arsenic  may  be 
said  to  be  gutta-percha  and  cement,  the  former  to  be  used  in  those 
cases  where  it  can  be  applied  to  the  surrounding  walls  of  the  cavity 
without  causing  pressure  toward  the  pulp,  and  the  latter  in  all 
cases  where  the  application  of  gutta-percha  is  difficult.  Cement 
may  be  gently  flowed  over  the  arsenic  and  made  to  adhere  per- 
fectly to  cavity  walls  without  pressure  on  the  pulp,  and  it  is  there- 
fore preferable  in  most  cases,  its  chief  drawback  being  the  greater 
difficulty  of  removal.  In  proximal  cavities  where  the  cavity-wall 
slopes  from  the  point  of  exposure  toward  the  gingival  margin  in 
such  a  way  as  to  present  an  incline  down  which  the  arsenic  may 
easily  be  forced  in  applying  the  cement,  the  danger  to  the  gum  in 
the  interproximal  space  is  very  great.  An  operator  may  readily 
force  some  of  the  arsenic  into  the  space  ahead  of  the  cement  with- 
out being  aware  of  it  till  serious  injury  results.  To  avoid  any 
possible  danger  of  this  nature,  it  is  advisable  in  every  instance 


DESTRUCTIO>'    OF    THE    PULP.  249 

where  ai-seiiic  is  to  be  applied  to  a  proximal  cavity  to  first  build  a 
layer  of  gutta-percha  over  the  gingival  wall  of  the  yig.  98. 

cavity  leading  from  near  the  point  of  exposure 
down  to  the  gingival  margin  of  the  cavity,  and 
across  the  interproximal  space  against  the  proxi- 
mating  tooth,  Fig.  98.  If  this  bridge  of  gutta- 
percha be  thus  constructed  with  care  before  the 
arsenic  is  applied,  the  operator  need  have  no  fear 
of  trouble.  In  these  cases  it  is  well  to  use  cement  over  the  arsenic, 
allowing  it  to  extend  against  the  proximating  tooth.  It  can  be 
applied  under  the  circumstances  with  less  danger  of  pressure  than 
gutta-percha,  and  it  is  not  so  compressible  under  mastication,  and 
therefore  less  liable  to  be  forced  into  the  cavity  so  as  to  impinge  on 
the  pulp. 

The  amount  of  arsenical  paste  required  to  destroy  a  pulp  is  very 
small.  Most  operators  use  altogether  more  than  is  necessary,  and 
thereby  increase  to  that  extent  the  danger  of  injury  to  the  .sur- 
rounding parts.  A  minute  quantity,  one-half  or  even  one-fourth 
the  size  of  the  head  of  an  ordinary  pin,  if  brought  in  immediate 
contact  with  the  pulp  will  be  found  ample  for  its  destruction.  A 
very  convenient  method  of  applying  it  is  to  first  place  the  required 
amount  on  a  porcelain  slab,  and  then  Avith  the  cavity  ready  for  its 
reception  a  small  pellet  of  cotton  moistened  in  the  oil  of  cloves  may 
be  used  to  pick  up  the  paste  and  earry  it  to  the  pulp.  Let  the 
paste  be  laid  immediately  over  the  exposure,  and  then  release  the 
pellet  of  cotton  so  that  it  remains  in  the  cavity  mth  the  paste. 
Cement  may  then  be  flowed  over  this  without  danger  of  pressure. 
If  this  is  dexterously  accomplished  there  is  seldom  any  appreciable 
pain  folloAving  the  application. 

The  length  of  time  necessary  for  the  arsenic  to  remain  may  be 
judiciously  varied  in  different  cases.  In  young  patients  where  the 
apical  foramina  are  large,  and  in  all  cases  where  for  any  reason 
there  may  be  doubt  about  the  security  of  the  sealing  agent,  the  ar- 
senic should  be  removed  at  the  end  of  twenty-four  hours,  but  it  is 
seldom  advisable  to  attempt  the  removal  of  the  pulp  at  this  time. 
While  the  arsenic  may  have  effectually  accomplished  its  purpose 


250  PEINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

SO  far  as  the  ultimate  destruction  of  the  pulp  is  concerned,  it  will 
ordinarily  be  found  that  sensation  persists  for  some  (^ays  after  the 
aj)plication.  In  fact,  it  is  usually  best  to  wait  a  week  or  ten  days 
before  removing  the  pulp,  to  give  ample  time  for  the  pulp  to  sever 
its  connection  at  the  apical  foramen.  Until  disintegration  takes 
place  at  this  point  there  is  always  more  or  less  sensation  on  its 
removal,  and  never  the  same  certainty  of  a  thorough  removal  to 
the  apex.  If  the  attempt  is  made  to  extract  the  pulp  while  it  is 
still  adherent  at  the  apex,  there  is  always  danger  of  tearing  the 
pulp  into  shreds  and  leaving  a  portion  of  it  in  the  canal.  De- 
composition and  infection  seldom  follow  immediately  on  the  de- 
struction of  the  pulp  where  it  is  carefully  sealed  from  the  fluids  of 
the  mouth,  so  that  it  may  safely  be  left  a  sufficient  time  to  in-- 
sure  its  painless  removal.  In  every  instance  where  the  arsenic 
is  removed  at  the  end  of  twenty-four  hours,  a  non-irritating  anti- 
septic should  be  placed  over  the  palp  and  the  cavity  sealed  with 
gutta-percha  till  the  pulp  is  ready  for  removal.  Under  no  cir- 
cumstances should  the  fluids  of  the  mouth  be  allowed  to  enter  the 
cavity  after  the  application  of  the  arsenic. 

In  the  teeth  of  adults  where  for  any  reason  the  patient  cannot 
conveniently  return  in  twenty -four  hours,  and  where  the  sealing 
may  be  made  secure,  it  is  permissible  to  leave  the  arsenic  in  for  one 
week,  at  the  end  of  which  time  the  pulp  may  be  removed  pain- 
lessly. In  leaving  arsenic  in  for  this  length  of  time  the  greatest 
care  must  be  exercised  in  sealing  it,  and  only  the  minutest  quantity 
of  arsenic  used. 

There  is  always  the  remote ,  danger  in  the  use  of  arsenic  that 
the  tooth  may  be  lost  through  a  peculiar  accident  whereby  the 
peridental  membrane  is  destroyed  without  any  leaking  of  -the 
arsenic  from  the  cavity  to  the  gum.  This  is  probably  due  to  the 
presence  in  such  cases  of  a  tributary  canal  leading  from  the  pulp- 
canal  proper  through  the  side  of  the  root.  In  any  event  such 
cases  have  been  reported  where  the  arsenic  was  left  in  the  tooth 
only  twenty-four  hours,  but  fortunately  they  are  very  rare, — so 
much  so  that  when  compared  with  the  very  general  use  of  arsenic 
for  pulp-destruction,  they  may  be  considered  only  in  the  light 
of  the  remotest  contingency. 


DESTRUCTIOX    OF    THE    PULP.  251 

Removing  the  Pulp  with  Cocaine. 

The  occasional  accidents  in  the  use  of  arsenic,  together  with 
the  length  of  time  necessary  for  its  action,  have  led  many  operators 
to  seek  other  means  for  removing  the  pnlp.  Probably  the  best 
method  is  to  force  a  solution  of  cocaine  into  the  pulp  to  destroy 
its  sensibility,  and  then  extract  it.  This  may  be  done  by  taking 
some  of  the  crystals  of  cocaine  and  making  a  solution  by  adding 
a  drop  or  two  of  alcohol  or  chloroform,  and  gathering  this  up  on 
a  small  pellet  of  cotton  and  placing  directly  over  the  pulp.  Pres- 
sure is  then  applied  to  this  in  such  a  way  as  to  force  the  solution 
into  the  pulp  by  taking  a  mass  of  unvulcanized  rubber  sufficient  to 
fill  the  entire  cavity,  and  with  a  broad-ended  instrument  driving 
this  toward  the  pulp.  The  pressure  should  be  gentle  at  first  and 
gradually  increased  as  the  pulp  will  tolerate  it  till  a  very  vigorous 
pumping  is  possible,  sufficient  to  force  the  solution  Avell  into  the 
pulp.  If  the  exposure  is  slight,  it  may  be  necessary  to  make  a  pre- 
liminary application  in  this  way  before  the  operator  can  secure  a 
broad  enough  exposure  to  carry  the  solution  well  into  the  pulp- 
tissue. 

This  method  of  pulp-destruction  seems  in  some  instances  to  work 
almost  like  magic,  the  pulp  evidently  yielding  at  once  to  the  in- 
fluence of  the  cocaine  to  such  a  degree  as  to  peniiit  of  its  removal 
without  the  slightest  disturbance  to  the  patient.  But  in  many 
other  cases  the  results  are  wholly  unsatisfactory.  It  is  notorious 
that  cocaine  does  not  act  uniformly  in  all  cases,  and  this  particular 
use  of  cocaine  seems  to  be  no  exception.  With  some  patients  the 
attempt  to  force  cocaine  into  a  pulp  in  this  manner  is  accompanied 
Avitb  most  excruciating  ])ain,  no  matter  how  gently  the  operator 
may  work,  nor  how  patient  he  may  be  in  waiting  for  the  pre- 
liminary effect  of  the  cocaine.  In  other  cases  the  most  strenuous 
effort  of  the  operator  fails  entirely  in  producing  anesthesia  of  the 
pulp,  the  solution  seemingly  having  no  effect  whatever.  An- 
other minor  limitation  of  the  method  relates  to  the  free  flow  of 
blood  following  the  removal  of  the  pu\]>  iindcr  these  conditions. 
It  is  sometimes  difficult  to  stop  the  flow  so  as  to  get  the  canal 
in    perfect   condition    for    the    reception    of    the  root-filling.      It 


S52 


PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 


Fig.  100. 


will  also  be  found  that  in  many  cases  following  this  kind  of 
treatment  a  disagreeable  soreness  develops  in  the  tooth,  lasting 
several  days,  though  seldom  resulting  in  anything  more  serious 
than  a  temporary  discomfort.  This  occurs  oftener  under  this 
method  than  where  the  pulp  has  been  destroyed  with  arsenic 
^nd  removed  in  the  ordinary  way. 

Removal  of  the  Pulp. 

The  operation  of  removing  the  pulp,  whether  it  has  been  de- 
stroyed with  arsenic  or  by  pressure  anesthesia,  is  sometimes  a  diffi- 
cult one,  particularly  in  small  and  tortuous  canals.     In  the  larger 
canals  which  contain  an  appreciable  mass  of  pulp-tissue  the  prob- 
lem is  much  simplified  by  the  ready  admission  of  a  Donaldson 
barbed  broach  or  an  Ivory  spiral  broach  (Figs.  99  and  100).     The. 
latter  in  a  canal  of  sufficient  size   to 
Fig.  99.        admit  it  will  grasp  the  pulp  and  engage 
it    more    securely   than   will   a   barbed 
broach, — the  barbs  sometimes  exhibiting 
a  tendency  to  tear  through  the  pulp- 
tissue  and  fall  short  of  extracting  it, — 
but  the  barbed  broach  will  enter  a  small- 
er canal  than  the  spiral  broach  on  ac- 
count of  its  lesser  bulk.     In  this  con-    i     B     | 
nection  it  may  be  stated  that  it  is  hazard- 
ous   to    introduce    into    any    canal    so 
constricted  that  the  broach  impinges  on 
the    canal    walls    while    being    turned, 
either  a  barbed  or  a  spiral  broach. 
The  attempt  to  remove  pulp-tissue  from  constricted  canals  with  a 
barbed  broach  is  accountable  for  many  a  broken  broach,  and  when 
a  piece  of  barbed  broach  is  thus  wedged  into  a  small  canal  it  is 
exceedingly  difficult  to  remove  it. 

Before  attempting  the  extraction  of  a  pulp,  the  approaches  to  it 
should  be  opened  up  to  give  the  best  possible  access.  The  roof 
of  the  pulp-chamber  should  be  well  cut  away  so  that  the  chamber 
is  exposed  to  view  and  the  orifices  of  the  canals  accessible.     If  in  a 


DESTRUCTION    OF    THE    PULP.  253. 

molar  the  large  bulbous  portion  of  the  pulp  in  the  chamber  may 
be  scooped  out  with  a  spoon  excavator,  leaving  the  openings  of  the 
canals  exposed.  The  chamber  should  now  be  flooded  with  alcohol 
and  thoroughly  washed  free  of  debris,  after  which  warm  air  may 
be  used  to  evaporate  the  moisture.  This  drying  out  must  not  be 
carried  sufficiently  far  to  endanger  the  integrity  of  the  tooth-sub- 
stance, the  tendency  being  to  render  teeth  brittle  and  easily  frac- 
tured when  subjected  to  extended  desiccation.  And  yet  it  would 
be  very  desirable  if  the  operator  could  extract  the  moisture  from 
the  pulp-tissue  before  attempting  its  removal  from  the  canals. 
The  drying  has  a  two-fold  beneficial  effect  upon  the  pulp, — it  less- 
ens its  bulk  so  as  to  shrink  it  away  from  the  walls  of  the  canal, 
and  it  toughens  it  so  that  it  may  be  more  readily  grasped  and  held 
by  the  broach.  In  many  of  these  cases  where  the  pulp  is  sensitive 
to  the  touch  of  the  broach  on  opening  up  the  chamber,  the  sensi- 
tiveness will  be  found  materially  reduced  by  desiccation.  A  pulp 
under  these  conditions,  though  sensitive  to  manipulation  by  the 
broach,  is  seldom  sensitive  to  thermal  changes  and  may  therefore 
be  dried  without  pain.  To  extract  the  moisture  from  the  pulp 
without  injuring  the  crown  of  the  tooth  it  is  sometimes  advisable  to 
carry  the  heat  directly  to  the  pulp  without  affecting  the  tooth-tis- 
sue. This  may  be  done  in  many  instances  by  following  the  appli- 
cation of  the  alcohol  with  a  heated  instrument  held  directly  against 
the  pulp  stump  in  each  root,  thus  drying  at  least  this  end  of  the 
pulp  and  converting  it  into  a  leathery  consistence  which  will  facili- 
tate its  removal. 

When  the  pulp  is  as  dry  as  practicable,  the  broach  may  be  car- 
ried along  its  side  as  far  into  the  canal  as  it  will  go  and  then  care- 
fully twisted  so  as  to  engage  the  pulp-tissue.  If  a  barbed 
broach  is  being  used,  the  barbed  side  should  be  placed  against  the 
wall  of  the  canal  and  the  smooth  side  in  contact  with  the  pulp- 
tissue  while  it  is  carried  into  the  canal,  and  then  so  turned  that 
the  barbs  grasp  the  pulp  before  its  withdrawal.  For  removing 
pulps  the  broaches,  whether  barbed  or  spiral,  should  be  used  with- 
out handles,  on  account  of  the  greater  facility  with  which  they 
may  be  made  to  enter  the  canal  at  the  desired  angle,  particularly 


254  PRINCIPLES    AIS'D    PEACTICE    OF    FILLING-    TEETH. 

in  posterior  teeth.  Bv  grasping  them  between  the  thumb  and 
index  finger  the  operator  can  direct  them  into  canals  far  back  in 
the  month,  and  reach  many  cases  advantageously  where  a  broach 
with  a  handle  could  never  be  made  to  enter  without  curving  it  so  as 
to  prevent  a  subsequent  twisting  for  the  removal  of  the  pulp. 

In  canals  too  small  for  insertion  of  the  barbed  broach — such, 
for  instance,  as  the  buccal  roots  of  upper  molars  and  the  mesial 
roots  of  lower  molars — the  safest  plan  is  to  ream  them  out  with 
a  smooth  broach  made  from  piano-mre  and  filed  so  as  to  leave 
sharp  angles  on  the  sides.  These  piano-wire  broaches  are  exceed- 
ingly tough  when  newly  made,  and  almost  any  canal  may  be 
advantageously  followed  by  them  to  a  point  where  the  constriction 
is  so  great  that  no  broach  will  pass. 

After  the  pulp-tissue  is  removed  from  the  canals  they  should 
be  flooded  with  alcohol  to  wash  out  any  remaining  fragments,  and 
when  thus  cleaned  the  canals  may  be  bathed  in  the  oil  of  cloves  to 
prevent  any  possible  infection,  and  then  flooded  with  alcohol  once 
more  previous  to  the  final  drying  for  the  reception  of  the  root- 
filling.  If  the  pulps  have  been  successfully  removed  and  the 
canals  rendered  clean  and  aseptic,  the  roots  may  be  filled  at  the 
same  sitting. 


CHAPTER   XVIII. 

FILLING  PULP-CANALS. 

The  selection  of  a  suitable  filling-material  for  pulp-canals  is  a 
question  that  has  engaged  the  minds  of  the  profession  ever  since 
pulpless  teeth  have  been  considered  worthy  of  saving.  Without 
going  into  the  history  of  the  various  materials  that  have  from  time 
to  time  been  advocated,  it  is  sufficient  to  say  that  the  most  uni- 
versal practice  to-day  is  to  use  gutta-percha.  This  material  has  pe- 
culiar qualities  entitling  it  to  favor  for  this  purpose,  and  while  it 
cannot  be  considered  ideal  in  all  respects  it  probably  fulfills  the  re- 
quirements to  a  greater  degree  than  any  other  one  material.     It  is 


FILLING    PULP-CAXALS.  255 

a  uoii-coriduetor  and  a  non-irritant.  It  can  be  molded  to  fit  the 
inequalities  of  any  canal,  and  be  made  to  follow  a  constricted  and 
tortuous  canal,  particularly  if  used  in  the  form  of  a  solution.  This 
solution  is  ordinarily  made  by  dissolving  gutta-percha  in  chloro- 
form to  a  cream-like  consistence,  and  then  pumping  this  into  the 
canals,  after  which  a  cone  of  solid  gutta-percha  is  forced  into  the 
canal  to  displace  all  of  the  solution  possible  and  leave  as  much 
as  may  be  of  the  canal  tilled  by  solid  gutta-percha. 

One  limitation  of  the  chloro-percha  solution  consists  in  the  fact 
that  the  chloroform  is  so  readily  evaporated  that  it  is  difficult 
to  keep  the  solution  of  a  proper  consistence  for  daily  use.  To 
provide  a  solution  for  this  purpose  which  will  remain  stationary, 
it  is  suggested  that  when  the  gutta-percha  is  dissolved  in  chloro- 
form and  the  latter  begins  to  evaporate  the  loss  of  fluidity  be  made 
good  by  the  addition  of  eucalyptol.  This  may  be  carried  on  till 
all  the  chloroform  is  gone  and  the  solution  consists  entirely  of 
gutta-percha  and  eucalyptol. 

This  solution  is  to  be  used  not  with  the  idea  of  forming  a  root- 
filling  of  itself,  but  merely  as  a  moistening  agent  for  the  canals 
preparatory  to  the  introduction  of  the  solid  gutta-percha,  which 
latter  will  follow  up  a  canal  to  better  advantage  under  these  con- 
ditions than  if  inserted  in  a  dry  canal. 

The  modus  operandi  of  filling  canals  with  gutta-percha  is  to 
first  flood  them  with  the  solution  by  dipping  a  small  pellet  of  cot- 
ton in  it,  and  carrying  this  to  the  pulp-chamber  and  squeezing  it 
out  against  the  side  of  the  chamber.  This  will  cause  the  solution 
to  flow  into  the  canals.  Then,  with  a  smooth  broach,  pump  the  so- 
lution well  into  the  canals,  and  thereby  displace  the  air  from  the 
canals  by  carrying  the  solution  to  the  ape.x.  In  constricted  canals 
this  pumping  with  the  broach  should  be  quite  vigorous,  but  in 
larger  canals  tiiere  is  not  the  same  necessity  for  extended  manipu- 
lation with  the  broach,  on  account  of  the  ready  flowing  of  the 
solution  to  the  apex  and  the  subsequent  insertion  of  the  gutta- 
percha cone.  In  fact,  too  much  manipulation  with  the  broach  iu 
large  canals  is  to  l>e  avoided,  on  account  of  the  possible  danger 
from  irritation  beyond  the  apex.   The  aim  should  be  in  these  cases 


256  PKINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

to  carry  the  solution  and  the  cone  just  to  the  apex  and  no  farther. 
This  is  often  a  delicate  matter,  but  by  a  close  study  of  these  cases 
the  operator  may  be  reasonably  certain  as  to  the  moment  the  apex 
is  reached..  There  is  no  rule  which  may  be  taught  as  an  infallible 
guide  to  indicate  just  when  the  apex  is  reached.  It  has  some- 
times been  suggested  that  the  evidence  of  an  approach  to  the  api- 
cal foramen  was  furnished  in  a  flinching  of  the  patient,  but  this  is 
by  no  means  reliable.  In  some  instances  where  the  foramina  are 
very  small  at  the  apex,  and  where  there  is  no  sensitive  tissue  be- 
yond the  root,  we  may  secure  a  most  thorough  filling  of  the  canal 
w^ithout  the  slightest  sensation  to  the  patient.  To  keep  on  pump- 
ing at  a  case  of  this  kind  looking  for  a  response  from  the  patient 
would  be  mistaken  zeal,  and  might  cause  subsequent  irritation. 
On  the  other  hand,  there  are  cases  where  the  slightest  pressure 
exerted  on  the  contents  of  a  canal,  even  where  the  pressure  is  so  far 
removed  as  the  entrance  to  the  canal  at  the  pulp-chamber,  will 
cause  a  ready  response.  This  may  be  due  to  the  pressure  of  air 
in  the  extremity  of  the  canal,  and  a  response  of  this  kind  would  be 
no  indication  whatever  that  the  filling-material  had  reached  the 
apex. 

The  whole  question  is  one  of  intuitive  perception  on  the  part 
of  the  operator,  and  of  such  a  training  of  the  faculties  and  fingers 
that  the  sensation  conveyed  to  the  practitioner  is  the  keynote,  and 
not  the  sensation  conveyed  to  the  patient. 

"When  the  canals  are  filled  with  the  solution  a  solid  gutta-percha 
cone  should  be  grasped  by  the  pliers  and  carried  into  each  canal, 
thereby  displacing  a  part  of  the  solution.  If  the  canal  is  so  large 
that  the  ordinary  cones  supplied  by  the  manufacturers  are  not 
large  enough  to  fill  it,  a  second  one  may  be  forced  in  beside  the 
first,  or  a  cone  may  be  made  by  the  operator  for  the  case  in  hand. 
Considerable  pressure  should  be  exerted  on  the  cone  to  make  it  fit 
up  tight  to  the  canal  at  the  apex.  Ordinarily  the  large  end  of  the 
cone  will  be  found  standing  up  in  the  chamber  after  it  has  been 
forced  as  far  as  possible  into  the  canal,  and  if  a  heated  instrument 
is  applied  to  this  in  the  attempt  to  compress  it  toward  the  canal, 
the  tendency  is  for  the  cone  to  adhere  to  the  instrument  and  be 


KILLING    PULP-CANALS.  257 

withdrawn  from  the  canaL  Instead  of  heating  the  instrnnient, 
the  end  of  the  cone  should  be  heated  by  directing  a  blast  of  hot  air 
upon  it,  and  then  a  broad-ended  instrument  may  be  used  to  com- 
press it  to  place.  In  some  instances,  particularly  in  three-rooted 
teeth  where  the  chamber  is  large,  it  may  be  well,  before  attempting 
to  compress  the  large  ends  of  the  cones,  to  warm  a  pellet  of  gutta- 
percha and  force  this  to  place  against  the  floor  of  the  chamber  or 
subpulpal  wall,  and  then  gather  the  ends  of  the  cones  over  into  the 
pellet  and  incorporate  the  whole  in  one  mass.  In  doing  this  the 
end  of  the  plugger  maj-  advantageously  be  wiped  oif  with  a  cloth 
saturated  with  one  of  the  essential  oils,  which  will  to  a  large  degree 
prevent  the  adhesion  of  the  gutta-percha  to  the  instrument. 

The  case  now  presents  with  the  cones  in  place  and  the  floor  of 
the  chamber  covered  with  gutta-percha,  but  the  canals  must  not 
be  considered  perfectly  filled.  There  is  yet  too  much  of  the  solu- 
tion remaining,  and  this  must  be  as  largely  displaced  as  possible 
by  the  solid  gutta-percha.  To  do  this  a  root-canal  plugger  should 
be  warmed  and  wiped  with  the  oiled  cloth,  and  gently  forced  into 
the  canals  in  such  a  way  as  to  drive  the  gutta-i)crcha  more  snugly 
inr<j  them.  >\.s  the  gutta-percha  is  compressed  into  the  canals  the 
solution  will  ooze  out  around  the  margins,  and  may  from  time  to 
time  be  absorbed  with  a  pellet  of  cotton.  This  forcing  process 
should  be  continued  till  there  is  assurance  that  the  canals  are 
solidly  filled  with  gutta-percha  and  all  the  surplus  solution  re- 
moved. Over  the  gutta-percha  thus  inserted  a  layer  of  cement, 
preferably  the  oxychloride  of  zinc,  should  be  used  upon  which  to 
build  the  permanent  filling.  Gutta-percha  does  not  present  a 
sufficiently  firm  or  stable  base  to  justify  an  operator  in  building  a 
metal  filling  upon  it. 

In  case  there  is  no  pericemental  soreness  the  ojieration  may 
be  completed  with  a  permanent  filling — whether  of  amalgam  or 
gold — at  the  same  sitting,  but  if  there  is  irritation  present  the 
cavity  should  l)e  temporarily  sealed  and  the  case  dismissed  for  a 
few  davs  till  the  soreness  subsides. 


17 


258  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

CHAPTEK   XIX. 

THE  TREATMENT  OE  PULPLESS  TEETH. 

When  a  pulp  dies  in  a  tooth  without  the  aid  of  the  operator,  the 
management  of  the  case  is  different  from  that  of  a  recently  de- 
stroyed pulp  where  the  tooth  has  been  under  the  operator's  super- 
vision from  the  destruction  of  the  pulp  to  the  final  filling  of  the 
root.  The  question  of  infection  enters  materially  into  the  case 
so  soon  as  the  natural  processes  of  dissolution  are  allowed  to  run 
their  course  without  interference. 

Cases  of  this  character  may  be  divided  into  three  classes, — those 
where  the  pulps  die  as  the  result  of  the  approach  of  caries,  and 
which  come  to  the  operator  with  the  cavity  and  canals  exposed  to 
the  fiuids  of  the  mouth;  those  where  the  pulps  die  under  a  filling, 
and  those  in  perfectly  sound  teeth  where  the  pulp  has  been  lost 
as  the  result  of  some  injury. 

Each  of  these  classes  may  present  in  one  of  the  following  condi- 
tions: There  may  be  no  apparent  disturbance  beyond  the  apex  of 
the  root,  with  no  soreness  or  inflammation  of  the  peridental  mem- 
brane and  no  pus,  or  there  may  be  decided  soreness  with  an 
elongation  of  the  tooth  from  a  swelling  of  the  membrane,  or  there 
may  be  an  absence  of  soreness  with  a  pus  pocket  beyond  the  apex, 
but  no  external  opening,  and  lastly,  there  may  be  an  abscess  with 
a  fistula  passing  through  the  alveolar  process  and  opening  on  the 
gum. 

Treatment  of  Pulpless  Teeth  where  the  Canals  have  been  Long 
Exposed  to  the  Fluids  of  the  Mouth,  but  where  there  is  No 
Fistulous   Opening. 

These  cases  must  always  be  treated  with  the  possibility  in  mind 
that  there  may  be  a  blind  and  passive  abscess  in  the  apical  space 
which  is  quite  likely  to  develop  into  a  fiery  furnace  by  a  little 
mismanagement.  The  actual  decay  in  the  cavity  should  first  be 
thoroughly  removed  and  the  pulp-chamber  well  opened  up.     This 


THE  TREATMENT  OF  PULPLESS  TEETH.  259 

must  be  done  without  the  slightest  manipulation  of  the  contents 
of  the  canals,  or  the  least  pressure  that  is  calculated  to  force  any- 
thing through  the  apical  foramen.  This  preliminary  cleansing 
of  the  cavity  may  be  done  without  the  application  of  the  rubber 
dam,  and  the  debris  may  be  rinsed  out  from  time  to  time  with  a 
syringe.  Make  the  cavity  and  chamber  as  mechanically  clean  as 
possible.  Then  apply  the  rubber  dam  and  absorb  the  moisture 
from  the  cavity  with  cotton.  Flood  the  cavity  and  chamber  with 
alcohol,  which  has  a  great  affinity  for  moisture,  and  absorb  the  al- 
cohol with  cotton.  This  will  often  extract  some  of  the  discolored 
and  putrescent  contents  of  the  canals.  Wash  out  well  with  alco- 
hol in  this  manner  till  the  alcohol  fails  to  be  discolored  by  contact 
with  the  cavity  and  chamber.  Then  dry  the  chamber  and  as  much 
of  the  canals  as  possible  with  warm  air,  but  do  not  carry  the  desic- 
cation so  far  as  to  weaken  the  tooth-structure.  jSTow  flood  the 
canals  and  chamber  with  a  non-irritating  antiseptic,  a  good  one  be- 
ing the  oil  of  cloves.  The  canals  must  not  at  this  sitting  be  en- 
tered by  a  broach,  and  no  attempt  made  to  clean  them  by  instru- 
mentation except  in  a  slight  degree  in  those  cases  where  the  canal 
is  very  large  and  filled  with  debris  and  putrescent  matter.  A 
canal  like  this  when  flooded  with  the  medicament  may  sometimes 
be  approached  very  gently  with  a  smooth  broach,  and  the  debris 
carefully  coaxed  out  and  floated  away  from  the  larger  portion  of 
the  canal  without  disturbing  the  contents  near  the  apex.  The 
reason  that  great  care  is  necessary  in  the  preliminary  treatment  of 
these  cases  is  because  if  the  slightest  bit  of  this  putrescent  matter 
be  forced  through  the  apical  foramen  it  is  almost  certain  to  set 
up  a  serious  inflammatory  process  which  may  run  to  abscess. 
After  the  chamber  and  canals  have  been  flooded  with  the  anti- 
septic, some  cotton  saturated  with  it  may  be  loosely  placed  in  the 
chamber  and  the  cavity  sealed  with  gutta-percha.  For  this  pur- 
pose the  temporary  stopping  may  be  used  to  good  advantage,  on 
account  of  its  being  easier  of  manipulation  than  the  base-plate 
gutta-percha. 

If  it  has  been  possible  to  secure  a  reasonably  perfect  cleansing 
of  the  tooth  and  there  seems  to  be  little  putrescence  left  in  the 


260  PEINCIPLES    AND    PKACTICE    OF    FILLING    TEETH. 

canals,  the  case  may  be  dismissed  for  one  week,  with  instruction 
to  report  at  once  in  case  of  trouble.  It  should  be  the  aim  of  the 
operator  from  this  time  forward  to  allow  nothing  in  the  tooth  ex- 
cept what  he  places  there,  and  if  trouble  ensues  it  is  better  for  the 
patient  to  seek  the  operator  and  let  him  change  the  dressing  rather 
than  to  pick  out  the  gutta-percha  and  again  admit  the  fluids  of  the 
mouth. 

In  case  the  dentine  seems  badly  infiltrated  with  putrescence  and 
the  first  treatment  has  apparently  failed  to  control  it  to  the  opera- 
tor's satisfaction,  he  would  better  not  let  the  case  go  a  week.  Un- 
der these  conditions  the  tooth  should  be  seen  in  twenty-four  or 
forty-eight  hours  and  the  treatment  repeated.  After  this  second 
dressing  the  case  may  be  dismissed  for  a  week.  If  the  tooth  re- 
mains sealed  up  for  this  time  without  discomfort,  the  operator  may 
safely  proceed  to  clean  out  the  canals.  They  should  first  be 
flooded  with  alcohol  and  manipulated  gently  with  a  smooth  broach 
to  float  any  particles  of  debris  that  may  have  been  packed  into 
them.  Even  at  this  second  sitting  the  operator  should  guard 
against  undue  irritation  of  the  apical  tissues  by  the  broach.  He 
should  aim  to  make  his  cleansing  as  thorough  as  possible  without 
forcing  anything  through  the  apex. 

This  mechanical  cleansing  of  the  canals  is  a  very  important 
part  of  the  successful  treatment  of  pulpless  teeth.  When  it  is 
remembered  that  the  cases  at  present  under  consideration  are  those 
in  which  the  contents  of  the  canals  have  long  been  subjected  to  the 
influences  of  infection  and  the  dentine  itself  is  more  or  less  infil- 
trated mth  poisonous  material,  it  must  be  apparent  that  the  most 
thorough  cleansing  with  instruments  should  supplement  any  or 
all  kinds  of  medication.  Many  operators  rely  too  largely  upon 
the  eflicacy  of  drugs  as  a  short  cut  to  excuse  them  from  the  neces- 
sity of  painstaking  care  in  removing  mechanically  every  particle 
of  the  putrid  contents  of  canals.  Medication  is  necessary,  but  it 
can  never  be  fully  effective  without  the  aid  of  instrumentation. 

To  be  successful  in  the  mechanical  cleansing  of  canals  it  is  im- 
portant to  first  gain  the  best  possible  access.  The  orifices  of  canals- 
leading  from  the  pulp-chamber  are  often  constricted  and  unap- 


THE    TKEATMENT    OF    PULPLESS    TEETH.  261 

proachable, — so  mnch  so  in  some  instances  as  to  make  it  difficult 
to  find  the  openings.  If  the  chamber  is  well  uncovered  these 
openings  may  readily  be  found  by  following  a  simple  procedure. 
Flood  the  chamber  with  alcohol  and  evaporate  it  with  warm  air, 
when  the  openings  will  ordinarily  be  plainly  visible  as  soon  as  the 
floor  of  the  chamber  is  dry.  These  orifices  should  at  once  be 
widely  reamed  out  with  a  large  Gates-Glidden  drill, — a  drill  too 
large  to  be  admitted  into  the  canal  proper, — so  as  to  form  a  funnel 
leading  to  the  canal.  This  reaming  out  will  perfectly  expose  the 
approach  to  the  canal  and  permit  the  operator  to  ascertain  the 
nature  of  the  canal  and  its  general  direction.  This  should  be  care- 
fully determined  with  a  smooth  broach,  and  in  cases  of  constricted 
canals  the  proper  cleansing  and  medication  of  the  canal  involves 
its  enlargement  by  the  operator. 

This  question  of  the  enlargement  of  canals  is  one  of  the  most 
intricate  connected  with  the  treatment  of  pulpless  teeth.  The  at- 
tempt to  enlarge  canals  with  drills  in  the  hands  of  careless  or  in- 
competent operators  has  been  prolific  of  disaster.  It  is  manifestly 
impossible  to  follow  a  curved  canal  with  a  drill,  and  the  inevitable 
result  has  been  that  operators  have  drilled  through  the  side  of  the 
root.  The  frequency  of  this  accident  has  led  many  conservative 
men  to  make  the  statement  that  a  drill  should  never  be  used 
for  enlarging  canals,  and  yet  in,  the  hands  of  a  careful  operator 
this  instrument  is  one  of  the  most  useful  we  have  in  the  manage- 
ment of  these  eases.  It  is  seldom  that  such  canals  as  those  in 
the  buccal  roots  of  the  upper  molars,  the  mesial  root  of  the 
lower  molars,  or  tlie  bifurcated  root  of  an  upper  first  bicuspid 
can  be  properly  cleaned  without  a  slight  enlargement.  Then 
again  there  are  many  of  the  larger  canals  in  which  there  is 
an  unevenness  along  the  walls  or  a  flattening  of  the  canal  which 
requires  a  reaming  out  to  be  properly  treated  and  filled.  In 
very  many  instances  this  may  be  safely  and  quickly  accom- 
plished with  a  drill, — at  least  in  the  first  third  or  half  of  the 
canal, — provided  the  operator  can  secure  the  proper  approach  to 
it,  and  will  first  study  the  direction  of  the  canal  with  a  broach. 
Unless  he  can  so  hold  the  drill  that  the  approach  is  at  the  proper 


262  PRINCIPLES    AND    PKACTICE    OF    FILLING    TEETH. 

angle,  he  would  better  not  attempt  to  drill  at  all.  Any  undue 
bending  of  the  drill  while  it  is  revolving  in  a  canal,  or  any  binding 
or  clogging,  is  quite  likely  to  result  in  the  drill  being  broken  and 
lodged  in  the  canal.  The  greatest  care  should  be  taken  to  avoid 
this,  and  consequently  it  is  never  permissible  to  exert  much  force 
on  the  drill  nor  to  attempt  to  drill  around  a  corner.  In  many 
instances  in  the  molars  and  bicuspids  the  drill  should  be  used  in 
the  right-angle  hand-piece  to  admit  of  the  proper  approach.  It 
should  be  passed  back  and  forth  in  the  canal  with  the  slightest 
pressure,  so  that  the  cutting  is  done  without  clogging,  and  most 
of  the  lateral  reaming  should  be  done  on  the  withdrawal  move- 
ment of  the  drill  instead  of  on  the  forward  movement. 

If  the  drill  is  thus  used  with  care  and  never  forced  too  near  the 
apex  it  is  capable  of  great  usefulness  in  the  preparation  of  roots 
for  filling,  but  there  are  some  cases  where  the  canals  are  so  curved 
and  the  approach  so  difficult  that  it  is  injudicious  to  attempt  to 
place  a  drill  in  them  at  all.  In  such  cases  the  canals  may  be  en- 
larged by  the  method  suggested,  by  Dr.  J.  R.  Callahan,  whereby 
a  solution  of  sulphuric  acid  is  used  to  soften  the  walls  of  the  canals 
so  that  they  may  be  readily  scraped  out  and  enlarged  with  a  Don- 
aldson cleanser.  The  manner  of  using  the  sulphuric  acid  is  as  fol- 
lows: A  forty  per  cent,  solution  of  commercial  sulphuric  acid 
should  be  prepared  and  kept  in  a  glass-stoppered  bottle.  A  drop 
or  two  of  this  may  be  carried  to  the  canals  by  winding  some  fibers 
of  cotton  on  a  wooden  point,  and  dipping  this  in  the  solution  and 
pressing  the  soaked  cotton  against  the  side  of  the  chamber  till  the 
solution  flows  down  into  the  canals.  This  should  then  be  pumped 
to  place  with  a  piano-wire  broach, — using  a  new  broach  each  time. 
When  the  smooth  broach  will  readily  pass  back  and  forth  in  the 
canal,  a  Donaldson  cleanser  may  be  used  to  further  pare  away  the 
sides  of  the  canal  and  enlarge  it.  As  soon  as  this  is  accomplished 
to  the  satisfaction  of  the  operator  the  chamber  and  canals  should 
be  freely  flooded  with  a  saturated  solution  of  sodium  bicarbonate 
to  neiitralize  the  further  effect  of  the  acid,  and  this  should  be  con- 
tinued till  all  effervescence  ceases.  The  canals  should  then  be 
dried  out  by  flooding  them  with  alcohol  and  evaporating  it  either 


THE  TREATMENT  OF  PULPLESS  TEETH.  263 

with  warm  air  or  a  heated  root-canal  drier.  The  latter  is  ordi- 
narily preferable  on  account  of  the  danger  to  the  crown  of  the 
tooth  by  the  use  of  air.  The  fact  should  always  be  noted  that  it 
is  unsafe  to  overheat  or  unduly  dry  the  tooth-tissue  on  the  crown, 
and  a  better  drying  of  the  canal  can  be  attained  without  jeopardy 
to  the  crown  by  the  use  of  a  canal  drier  than  with  a  diffused  blast 
of  warm  air.  As  soon  as  the  canal  is  dry  it  should  immediately 
be  flooded  with  the  oil  of  cloves,  which  will  under  these  conditions 
penetrate  not  only  to  the  apex  of  the  root,  but  be  absorbed  more 
or  less  by  the  open  ends  of  the  dentinal  tubuli  leading  from  the 
canal. 

If  the  case  has  progressed  favorably  up  to  this  point  and  there 
are  no  untoward  symptoms,  the  canals  may  be  filled  at  this  sitting. 
Preparatory  to  this  the  oil  of  cloves  should  be  wiped  out  and  some 
more  alcohol  used  for  dryness.  The  moment  the  canals  are  dried 
the  eucalyptol  solution  should  be  at  hand  for  use,  so  that  the  den- 
tine is  not  kept  desiccated  for  any  length  of  time. 

In  those  cases  where  the  canals  have  long  been  exposed  to  the 
fluids  of  the  mouth  there  is  always  the  possibility  of  an  abscess 
occurring  in  the  apical  space  and  discharging  through  the  tooth, 
thus  giving  no  external  evidence  of  its  existence.  In  such  cases 
tlie  operator  will  ordinarily  be  able  to  detect  the  presence  of  pus 
either  in  his  preliminary  work  on  the  canals,  or  at  least  on  the  cot- 
ton after  it  has  been  sealed  in  the  tooth.  As  soon  as  pus  is  demon- 
strated the  management  of  the  case  is  slightly  changed.  The 
canals  should  at  once  be  thoroughly  cleansed,  and  all  the  pus  re- 
moved that  is  possible  by  coaxing  it  from  the  apex  toward  the 
chamber  with  a  broach,  and  then  absorbed  with  cotton  or  with 
bibulous  paper  cones  prepared  for  this  purpose.  When  no  more 
pus  can  be  extracted  the  canals  should  be  flooded  with  an  antiseptic 
and  some  cotton  placed  in  the  chamber,  and  the  cavity  sealed.  If 
there  has  been  much  pus,  and  particularly  if  it  has  been  of  an 
offensive  character,  the  case  should  be  seen  in  twenty-four  hours 
and  the  treatment  repeated.  At  the  second  sitting  the  condition 
of  the  case  w\]\  indicate  the  line  of  treatment.  If  there  has  been 
perceptible  improvement  there  need  be  very  little  manipulation 


264  PKINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

with  the  broach,  but  merely  a  change  of  dressing.  If  the  pus 
seems  as  bad  as  ever  the  broach  should  be  freely  used,  and  in  some 
instances  it  will  be  found  beneficial  to  work  with  the  broach  till 
all  pus  is  removed  and  a  tinge  of  blood  follows  it  into  the  canal. 
As  soon  as  the  blood  shows  it  is  well  to  pack  the  canal  with  cotton 
saturated  with  the  antiseptic,  and  seal  the  cavity.  Under  these 
conditions  the  case  may  be  dismissed  for  a  week  with  instructions 
to  report  in  the  event  of  trouble.  If  at  the  end  of  this  period  there 
is  still  pus,  it  is  well  to  inject  peroxide  of  hydrogen  into  the  abscess 
and  let  it  effervesce  through  the  tooth.  Peroxide  of  hydrogen  is 
not  indicated  at  the  outset  before  the  canals  have  been  disinfected, 
through  fear  of  irritation  following  the  effervescence.  This  dan- 
ger is  not  so  great  after  the  first  treatment.  When  effervescence 
has  ceased  the  canal  may  again  be  packed  with  an  antiseptic,  and 
the  case  dismissed  for  two  weeks.  After  the  first  thorough  dis- 
infection of  the  canal  the  tooth  should  not  be  treated  frequently, 
unless  the  operator  is  forced  to  do  so  by  pain.  Many  of  these 
cases  are  kept  in  a  state  of  irritation  by  too  much  operative  inter- 
ference, and  it  mil  often  be  found  a  very  effective  practice  to  give 
nature  a  chance. 

^Vlien  the  character  of  the  discharge  changes  from  a  thick  yel- 
lowish pus  to  a  thin  serous  fluid, — which  is  very  frequently  the 
case, — the  canal  should  be  packed  tight  to  the  apex  with  cotton 
saturated  in  an  antiseptic,  and  the  case  left  long  enough  to  give 
it  an  opportunity  to  dry  up.  Except  in  stubborn  cases  this  will 
usually  occur  in  two  weeks,  and  when  the  tooth  has  remained  for 
that  length  of  time  free  from  trouble,  while  tightly  sealed,  it  may 
be  considered  safe  to  fill  it,  provided  the  canal  can  be  perfectly 
dried  to  the  apex. 

Treatment  of  Pulpless  Teeth   having  a  Fistulous  Opening  on 

the  Gum. 

Whether  the  fistula  proceeds  from  a  tooth  with  a  filling  in  it  or 
with  an  open  cavity,  the  first  treatment  involves  the  thorough 
opening  up  of  the  chamber  and  canals,  and  the  most  painstaking 
cleansing  to  the  very  apex  if  possible.     With  a  fistula  leading  from 


THE    TKKAT.MKXT    OF    TL'LPLESS    TEETH.  26.J 

the  abscess  there  is  little  danger  of  setting  up  inflammation  by  the 
use  of  broaches  or  drills  in  the  canals,  and  the  more  thoroughly 
this  initial  cleansing  is  done  the  more  readily  may  the  abscess  be 
brought  under  control.  After  the  canals  are  cleansed,  the  one 
from  which  the  abscess  comes — a  fact  which  may  usually  be  de- 
termined by  passing  a  probe  into  the  fistula  and  tracing  its  direc- 
tion— should  be  packed  with  cotton  saturated  with  a  non-irritating 
antiseptic  such  as  the  oil  of  cloves,  and  pressure  brought  to  bear 
upon  it  so  as  to  force  the  agent  through  the  fistula  till  it  appears  on 
the  gum.  This  may  ordinarily  be  best  accomplished  by  placing 
a  mass  of  unvulcanized  rubber  into  the  cavity  and  exerting  pres- 
sure upon  it  with  a  broad-ended  instrument  with  a  pumping  mo- 
tion toward  the  orifice  of  the  canal.  This  will  cause  compression 
on  the  contents  of  the  canal  and  force  the  medicament  through 
the  fistula.  As  soon  as  it  appears  on  the  gum  the  rubber  may  be 
removed  and  the  cotton  changed  for  a  freshly  saturated  piece,  and 
the  cavity  sealed  for  one  week.  Usually  the  fistula  will  be  found 
healed  at  the  end  of  this  time  if  the  first  treatment  has  been  thor- 
ough, but  in  case  the  fistula  still  persists  the  treatment  may  l)e 
repeated.  When  a  case  exhibits  this  tendency  to  a  chronic  con- 
dition it  is  well  at  the  second  treatment  to  substitute  carbolic  acid, 
ninety-five  per  cent.,  for  the  essential  oil.  It  is  a  rare  case  indeed 
which  ^vill  not  heal  in  response  to  a  thorough  injection  of  this 
agent  through  the  fistula.  The  same  rule  in  regard  to  waiting  to 
give  nature  a  chance  after  the  first  or  second  treatment  should  be 
followed  here  as  with  the  previous  cases  under  consideration.  Many 
a  chronic  case  will  heal  in  two  Aveeks  when  it  will  not  heal  in  one. 
In  case  a  second  or  third  injection  of  the  carbolic  acid  fails  to 
close  the  fistula  it  may  be  taken  for  granted  that  there  is  some 
caries  of  the  process  surrounding  the  apex  of  the  root,  or  such  a 
roughening  of  the  end  of  the  root  as  to  prevent  the  tissues  from 
healing  over  it.  Under  these  conditions  the  root-canal  should  be 
filled  and  the  external  fistula  packed  with  cotton  to  enlarge  it. 
The  cotton  should  be  changed  every  twenty-four  hours  for  a  larger 
piece  till  the  fistula  is  sufficiently  expanded  to  pennit  of  perfect  ac- 
cess to  the  end  of  the  root.     When  this  is  attained  a  shar])  bur  in 


266  PEINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

the  engine  should  be  used  to  ream  out  the  carious  bone  and  smooth 
the  rough  end  of  the  root, — ^if  necessary,  cutting  off  a  piece  of  the 
root.  The  opening  thus  made  should  be  syringed  out  with  an  an- 
tiseptic solution  and  freely  plastered  with  a  paste  made  by  mixing 
boracic  acid  with  oil  of  cloves,  after  which  some  antiseptic  gauze 
should  be  packed  into  it  to  keep  it  from  healing  at  the  orifice  be- 
fore granulations  have  perfectly  filled  in  the  interior.  The  dress- 
ing  should  be  changed  every  twenty-four  hours,  and  as  the  open- 
ing heals  from  mthin  the  gauze  may  be  made  less  and  less  till  it  is 
not  required  at  all.  This  will  cure  the  most  stubborn  case, — and 
it  xaay  be  said,  in  passing,  that  it  is  only  the  very  stubborn  cases 
that  call  for  it,  the  vast  majority  of  abscesses  usually  healing 
without  recourse  to  such  surgical  interference.  It  should  be  the 
aim  of  the  operator  to  cure  all  cases,  if  possible,  by  treatment 
through  the  pulp-cianal  in  the  ordinary  way,  but  where  this  opera- 
tion seems  imperatively  necessary  it  must  not  be  considered  a  very 
serious  or  formidable  one.  A  little  delicacy  -on  the  part  of  the 
practitioner  will  usually  enable  him  to  perform  it  without  ap- 
preciable pain  to  the  patient. 

Opening   into  Filled  Teeth  in  which  the  Pulps  have   Died,   but 
have  Lain  Dormant. 

It  will  occasionally  be  found  that  pulps  die  under  fillings  with- 
out giving  any  particular  trouble  to  the  patient,  and  the  tooth  re- 
mains passive  for  an  indefinite  time  with  no  indication  of  abscess. 
In  opening  into  these  teeth  for  the  purpose  of  treating  and  filling 
the  canals  the  very  greatest  care  is  necessary  to  avoid  trouble. 
There  seems  to  be  a  disposition  in  such  cases  for  the  most  active 
inflammation  to  ensue  the  moment  an  opening  is  made  through  the 
filling.  This  is  all  the  more  embarrassing  to  the  operator  in  view 
of  the  fact  that  the  trou'ble  dates  from  the  time  of  his  interference 
with  the  case,  and  it  is  sometimes  difficult  to  explain  to  the  patient 
that  it  is  not  due  to  his  carelessness.  These  cases  should  therefore 
be  approached  with  the  utmost  caution,  and  everything  should  be 
in  readiness  for  immediate  medication  the  moment  the  drill  pene- 
trates through  the  filling.     On  account  of  its  dehydrating  proper- 


THE  TREATMENT  OF  PULPLESS  TEETH.  267 

ties,  alcohol  would  seem  to  be  the  best  agent  for  the  first  flooding 
of  the  cavity.  This  should  be  conveniently  at  hand,  and  at  once 
admitted  to  the  opening  when  the  drill  passes  into  the  chamber. 
After  letting  it  remain  a  moment,  the  surplus  may  be  absorbed 
with  cotton  followed  by  warm  air  till  the  cavity  is  dry.  The 
opening  through  the  filling  may  be  then  enlarged  as  indicated,  and 
the  cavity  again  flooded  with  alcohol.  A  very  gentle  stirring  of 
the  alcohol  in  the  chamber  is  permissible  with  the  object  of  wash- 
ing out  any  debris  or  putrescent  matter  that  may  be  present,  but 
no  attempt  should  be  made  to  use  instruments  in  the  canals 
through  fear  of  forcing  infectious  matter  beyond  the  apex.  After 
the  chamber  is  well  washed  with  alcohol  it  should  be  dried  again, 
and  a  pellet  of  cotton  saturated  with  oil  of  cloves  placed  loosely 
in  the  chamber  and  the  opening  sealed  with  gutta-percha.  The 
subsequent  management  of  the  case  is  the  same  as  that  already  out- 
lined for  the  treatment  of  pulpless  teeth  having  no  fistulous  open- 
ings. 

The  Management  of  Pulpless  Teeth  in  the  Anterior  Part  of  the 
Mouth  to   Prevent  Discoloration. 

The  tendency  of  all  pulpless  teeth  to  take  on  discoloration  ren- 
ders it  necessary  for  the  operator  to  exercise  especial  caution  with 
teeth  exposed  to  view,  to  avoid  as  largely  as  may  be  the  resultant 
disfigurement  of  his  patient.  If  a  pulp  must  be  lost  in  an  incisor, 
it  is  preferable,  if  possible,  to  destroy  it  by  means  of  pressure  an- 
esthesia rather  than  to  apply  arsenic,  on  account  of  the  fact  that 
many  cases  are  on  record  where  the  application  of  arsenic  has  re- 
sulted in  a  sudden  clouding  of  the  tooth  from  the  active  inflam- 
mation induced.  If  it  is  deemed  necessary  to  use  arsenic,  only 
a  very  small  quantity  should  be  used,  and  it  should  not  be  allowed 
to  remain  longer  than  twenty-four  hours.  At  the  end  of  this 
time  the  arsenic  should  be  removed,  and  the  cavity  washed  out 
with  alcohol  and  dried,  after  which  some  light-colored  antiseptic 
may  be  sealed  in  the  cavity  for  one  week, — using  cement  as  the 
sealing  agent.  It  should  be  a  cardinal  principle  in  the  treatment 
of  these  cases  never  to  allow  the  fluids  of  the  mouth  to  gain  en- 


268  PRINCIPLES    AND    PKACTICE    OF    FILLING    TEETH. 

trance  to  the  cavity  after  the  case  comes  under  the  care  of  the 
operator,  and  in  the  sealing  of  medicaments  it  is  safer  to  use 
cement  than  gutta-percha.  The  latter  may  not  be  so  permeable 
to  moisture  under  long-continued  exposure  as  the  former,  but  the 
ready  adaptation  and  adhesion  of  cement  to  cavity  walls  renders 
it  the  most  certain  sealing  agent.  Along  this  same  line  no  treat- 
ment should  ever  be  made  without  the  application  of  the  rubber 
dam. 

As  soon  as  the  pulp  is  removed  and  the  canal  dried  the  root 
should  be  filled,  and,  if  possible,  a  permanent  filling  inserted  in 
the  crown  at  the  same  sitting.  If  these  precautions  are  taken  it 
will  seldom  be  found  that  a  tooth  becomes  sufficiently  discolored 

to  be  noticeable. 

Bleaching  Teeth. 

It  is  scarcely  within  the  province  of  the  present  work  to  go 
minutely  into  the  subject  of  treating  discolored  teeith,  but  a  simple 
suggestion  miay  be  made  as  to  a  certain  method  of  bleaching  which 
will  be  found  effective  in  a  large  percentage  of  cases  applying  to 
the  operator.  When  a  tooth  presents  which  has  become  dis- 
colored as  the  result  of  loss  of  the  pulp,  the  first  consideration  is 
to  put  the  canal  in  a  healthy  condition  and  fill  it.  Then  the  tooth 
may  be  bleached  in  the  foUomng  way:  The  root-filling  should  be 
removed  sufficiently  to  allow  the  bleaching  agent  to  act  on  the 
tooth  well  under  the  line  of  the  free  margin  of  the  gum, — ^many 
of  these  cases  showing  the  most  marked  discoloration  near  the 
gum.  The  cavity  should  then  be  dried  out,  and  a  pellet  of  cotton 
saturated  with  a  fresh  solution  of  the  twenty-five  per  cent,  pyro- 
zone  should  be  sealed  in  the  cavity  with  cement  for  twenty-four 
or  forty-eight  hours,  at  the  end  of  which  time  a  very  perceptible 
bleaching  will  ordinarily  have  occurred.^  In  some  stubborn  cases 
it  may  be  necessary  to  repeat  the  treatment, — always  being  careful 
to  apply  the  rubber  dam  at  each  sitting,  and  invariably  sealing 
with  cement.  If  this  method  is  carefully  followed  the  results  are 
usually  very  gratifying  and  the  bleaching  quite  permanent. 


illE    .MANAGEMENT    OF    CHILDREN'S    TEETH.  269 

CHAPTER    XX. 

THE  3IANAGEMENT  OF  CHILDREN  S  TEETH. 

This  subject  presents  itself  in  two  phases  for  onr  consideration 
from  an  operative  point  of  view, — the  care  of  the  deciduous  teeth, 
and  the  care  of  those  of  the  permanent  set  which  may  be  said  to 
appear  in  childhood.  The  problems  which  confront  the  operator 
in  the  one  case  are  not  precisely  the  same  as  those  in  the  other,  and 
the  intelligent  practitioner  will  study  the  two  situations  from  a 
somewhat  different  basis.  The  object  in  the  management  of  the 
deciduous  set  is  merely  to  do  palliative  work,  with  the  idea  of 
keeping  the  patient  comfortable  for  a  period  of  a  few  years,  rather 
than  to  undertake  thorough,  permanent,  and  artistic  operations. 
The  avoidance  of  pain  at  this  stage  is  very  important,  and  this  of 
itself  often  involves  the  performance  of  temporary  work.  While 
the  operator  is  not  by  any  means  free  from  this  restriction  in  his 
management  of  the  permanent  teeth,  particularly  those  which  ap- 
pear early,  yet  his  aim  as  he  approaches  these  should  be  in  the  di- 
rection of  attaining  the  greatest  possible  permanence  to  his  opera- 
tions, with  the  idea  ever  in  mind  that  the  highest  exercise  of  his  art 
involves  the  saving  of  these  organs  for  a  lifetime. 

Management  of  the  Deciduous  Teeth. 

The  impression  among  many  of  the  laity  that  these  teeth  may 
well  be  neglected,  so  far  as  operative  procedures  are  concerned,  on 
the  basis  that  they  are  eventually  lost  through  natural  processes, 
should  be  corrected  by  the  profession  at  every  opportunity.  Be- 
yond the  patent  fact  of  much  possible  suffering  on  the  part  of  the 
patient  and  much  injury  to  the  health  through  neglected  and  ab- 
scessed teeth,  there  is  a  question  of  habit  which  would  seem  to  have 
an  important  bearing  on  the  future  welfare  of  the  patient.  These 
little  folk  are  very  impressionable  at  such  a  tender  age,  and  readily 
acfjuire  habits  which  may  conduce  to  either  their  permanent  bene- 


270  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

fit  or  injury.  If  a  deciduous  tooth  decays  and  is  allowed  to  go 
without  attention,  it  sooner  or  later  becomes  sensitive  to  the  impact 
of  food  in  mastication,  and  the  little  patient  often,  without  being 
able  to  explain  the  real  source  of  the  discomfort,  intuitively  avoids 
chewing  upon  the  side  of  the  mouth  affected.  This  leads  to  im- 
perfect mastication,  and  where  there  are  several  sensitive  teeth  in 
the  mouth  it  may  lead  to  an  almost  entire  cessation  of  mastication; 
so  that  a  process  of  bolting  the  food  is  inaugurated  which  may,  and 
undoubtedly  often  does,  cling  to  the  patient  as  a  habit  through  life. 

If  a  close  observer  will  carefully  note  the  workings  of  mastica^ 
tion  in  the  mouths  of  the  individuals  he  meets,  he  may  of  course  get 
a  reputation  for  rudeness,  but  he  will  also  be  impressed  with  the 
variations  in  the  methods  practiced  and  the  degree  of  effectiveness 
exemplified  in  the  different  mouths.  These  variations  occur  in 
individuals  who  have  teeth  of  relatively  equal  efficiency,  so  that 
they  must  be  traced  largely  to  matters  of  habit;  and  it  is  natural  to 
conclude  that  these  habits  were  formed  in  childhood.  When  it  is 
considered  that  effective  mastication  is  a  weighty  factor  in  the 
health  and  longevity  of  the  individual,  it  may  be  seen  how  impor- 
tant it  becomes  that  we  keep  the  teeth  of  children  in  a  condition 
comfortable  under  the  trituration  of  food  and  conducive  to  habits 
of  thorough  mastication. 

A  child  should  be  brought  to  the  dentist  at  regular  intervals  for 
examination  from  the  time  of  the  third,  or  at  latest  the  fourth,  year 
of  age.  The  first  operation  usually  necessary  is  fortunately  that 
of  cleaning  the  teeth,  and  this  may  be  accomplished  as  a  sort  of  a 
frolic  on  the  part  of  the  little  patient  and  without  any  pain.  If  the 
teeth  are  cleaned  several  times  before  any  filling  becomes  neces- 
sary the  dread  of  the  dental  chair  is  largely  overcome,  and  filling 
operations  are  undertaken  with  a  better  prospect  of  success. 

The  materials  to  be  used  for  filling  the  deciduous  teeth  are  ordi- 
narily limited  to  gutta-percha,  cement,  and  amalgam.  For  the 
anterior  teeth  cement  must  be  considered  the  chief  reliance,  on 
account  of  the  nature  of  the  decay  which  usually  attacks  these 
teeth.  The  cavities  are  for  the  most  part  shallow  and  not  well 
defined  in  outline,  nor  is  it  possible  in  many  instances  to  establish  a 


THE    MANAGEMENT    OF    CHILDREN'S    TEETH.  271 

perfect  outline  or  trim  to  a  well-formed  margin.  After  the  re- 
moval, more  or  less  thoroughly,  of  the  decay,  the  filling  must  be 
plastered  against  the  decayed  surface  and  remain  by  its  OAvn  ad- 
hesive properties.  Cement  is  the  only  material  which  can  be 
relied  upon  to  do  this,  the  fact  that  it  is  necessary  to  renew  it  occa- 
sionally being  its  chief  limitation.  It  is  ordinarily  not  a  very  diffi- 
cult problem  to  save  the  deciduous  incisors  and  keep  them  comfort- 
able till  the  eruption  of  the  permanent  ones,  on  account  of  the  early 
age  at  which  they  are  shed;  but  the  care  of  the  deciduous  molars 
becomes  a  more  serious  matter.  They  are  usually  retained  four 
or  five  years  longer  than  the  incisors,  and  those  years  are  sometimes 
very  trying  both  to  patient  and  operator.  Occlusal  cavities  in 
these  teeth  are  ordinarily  easily  managed  with  either  cement  or 
amalgam,  the  choice  being  governed  by  the  degree  of  thoroughness 
with  which  the  cavity  may  be  excavated  without  pain.  If  a  good 
preparation  can  be  made,  and  the  pulp  is  not  too  nearly  involved, 
amalgam  should  be  used  on  account  of  its  greater  permanence,  but 
in  some  instances  the  teeth  are  so  sensitive  that  the  most  that  can 
be  accomplished  is  to  break  down  the  thin  overhanging  enamel- 
walls,  remove  the  softer  portions  of  the  carious  dentine,  and  force 
cement  into  the  cavity.  When  cement  is  used  under  these  condi- 
tions it  should  be  placed  in  position  with  considerable  pressure.  It 
should  also  be  used  in  such  excess  that  the  entire  occlusal  surface  of 
the  tooth  is  covered  even  beyond  the  borders  of  the  cavity,  so  far 
as  this  may  be  done  without  interfering  with  the  occlusion.  To 
accomplish  this  conveniently,  and  also  to  protect  the  filling  from 
moisture  for  a  few  minutes  without  stuffing  the  mouth  full  of 
napkins  or  absorbent  rolls,  the  index  finger  of  the  operator  may  be 
brought  down  upon  the  cement  as  it  lies  on  the  tooth  and  the  whole 
occlusal  surface  subjected  to  pressure,  so  that  the  cement  will  be 
forcibly  carried  into  every  groove  or  inequality  on  this  surface  and 
the  excess  be  squeezed  out  over  the  marginal  ridges  of  enamel. 
If  the  finger  be  held  upon  the  cement  a  few  minutes  the  result  is  a 
filling  which  not  only  includes  the  cavity  itself,  but  also  protects 
the  grooves  and  other  vulnerable  points  radiating  from  it. 

'J'he  problem  of  chief  concern  in  tlie  care  of  these  teeth  relates  to 


272  PEINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

the  management  of  occluso-proximal  cavities.  There  are  two  fac- 
tors which  tend  to  make  these  cavities  especially  difficult  to  con- 
trol,— the  almost  universal  sensitiveness  which  we  find  present, 
thus  preventing  an  adequate  preparation  of  the  cavity  to  retain  the 
filling,  and  a  gradual  separating  of  the  teeth  from  the  natural  ex- 
pansion of  the  jaw,  so  as  to  lead  to  constant  complaint  on  the  part 
of  the  patient  of  food  wedging  between  the  filling  and  the  proxi- 
mating  tooth  and  lodging  in  the  interproximal  space.  This  dis- 
comfort is  often  manifest  as  the  teeth  drift  apart,  even  when  no 
decay  lias  occurred,  but  it  is  particularly^  annoying  between  filled 
teeth  where  it  has  not  been  possible  to  contour  sufficiently  to  main- 
tain perfect  contact  with  the  proximating  tooth.  The  insecurity 
of  anchorage  usually  imposes  upon  the  operator  the  alternative  of 
making  fillings  with  limited  contour,  and  this  soon  leads  to  a 
pocket  between  the  teeth,  which  proves  a  constant  source  of  dis- 
comfort. 

Ordinarily  where  the  proximal  surface  of  a  molar  is  decayed 
the  proximating  surface  of  the  one  next  to  it  also  becomes  in- 
volved, and  this  complicates  matters  so  far  as  making  separate  fill- 
ings is  concerned.  In  desperate  cases,  where  both  teeth  are  de- 
cayed, it  may  be  advisable  to  bridge  across  the  interproximal 
space  and  join  the  fillings  together.  This  will  at  once  do  away 
with  the  difficulty  of  food  wedging  between  the  teeth,  and  will 
often  prove  a  relief  to  the  patient  where  separate  fillings  have  been 
a  failure.  But  there  are  only  two  materials  which  are  suitable  for 
this  purpose.  If  cement  is  employed  it  is  only  a  matter  of  a  few 
weeks  when  the  whole  mass  is  found  loose  between  the  teeth;  so 
that  the  operator  is  limited  to  gutta-percha  and  amalgam.  If  tlie 
former  is  used  it  will  ordinarily  not  draw  away  from  either  cavity, 
and  it  is  excellent  as  a  temporary  expedient,  but  it  is  so  easily  worn 
out  that  it  is  at  best  only  a  makeshift.  Amalgam  is  probably  the 
most  serviceable  material  for  these  cavities.  It  is  not  worn  away 
by  attrition,  and  will  remain  more  securely  fixed  than  cement,, 
though  in  some  instances  the  case  will  present  in  a  few  months  with 
the  filling  loosened  from  one  of  the  cavities  while  the  other  remains 
firm.  The  reason  for  this  lies  in  the  individual  movement  of  tlie 
teeth,  the  one  with  the  lesser  retention  giving  way. 


THE    MAN^AGEMEXT    OF    CHILDREN'S    TEETH.  273 

A  great  aid  in  securing  firmness  of  these  fillings  when  joined  to- 
gether, no  matter  which  material  is  used,  is  to  first  place  a  metal 
bar  across  the  intei-proximal  space,  with  one  end  resting  on  the 
gingival  wall  of  one  cavity  and  the  other  on  the  gingival  wall  of 
the  other,  and  building  the  fillings  around  and  over  it.  This  locks 
the  teeth  together  more  securely,  and  affords  perfect  protection  to 
the  gum.  These  bars  may  conveniently  be  made  from  German 
silver  wire  rolled  flat,  and  cut  to  a  suitable  length  for  the  case  in 
hand. 

Treatment  of  Exposed  Pulps  in  Deciduous  Teeth. 

When  a  pulp  becomes  exposed  in  a  deciduous  tooth,  it  is  seldom 
advisable  to  make  an  application  for  its  destruction.  If  the  patient 
applies  with  pain  this  can  ordinarily  be  quickly  relieved  by  syring- 
ing the  cavity  well  with  tepid  water  to  remove  loose  debris,  and 
carefully  clearing  away  with  a  spoon  excavator  any  hard  material 
which  may  be  causing  pressure  on  the  pulp.  This  is  to  be  followed 
by  an  application  of  oil  of  cloves  on  a  pledget  of  cotton  about  the 
size  of  the  head  of  a  pin,  covered  with  dry  cotton  to  fill  the  cavity. 
When  the  pain  is  relieved,  it  is  better  to  treat  the  tooth  in  a  pallia- 
tive way  than  to  subject  the  pulp  to  the  action  of  drugs  sufficiently 
powerful  to  work  its  destruction.  Arsenic  should  never,  under 
any  circumstances,  be  used  in  a  deciduous  tooth.  The  risk  is  too 
great  of  doing  serious  injury  to  the  surrounding  parts,  and  the 
necessities  of  the  case  seldom  call  for  any  such  radical  treatment. 

An  exposed  pulp  may  be  treated  by  flowing  over  it  a  paste  made 
by  mixing  oil  of  cloves  with  the  oxide  of  zinc  or  the  powder  which 
comes  with  cement  fillings.  This  paste  is  anodyne  and  antiseptic, 
and  a  pulp  will  usually  remain  comfortable  under  it.  It  should  be 
protected  by  a  filling  of  gutta-percha  or  cement.  If  a  pulp  has 
begun  to  suppurate,  this  paste  sealed  in  with  soft  gutta-percha  is 
an  excellent  means  of  keeping  the  tooth  comfortable  while  the  pulp 
is  dying.  It  may  be  left  in  under  these  conditions  for  a  week  or 
two,  as  the  case  indicates,  and  on  its  removal  the  canals  can  ordi- 
narily be  cleaned  and  filled  with  safety.  It  will  usually  be  found 
that  when  a  pulp  has  once  become  exposed  in  a  deciduous  tooth  it 

IK 


274  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

is  onlj  a  matter  of  time  when  it  will  die.  These  pulps  do  not  seem 
to  be  very  tenacious  of  life,  and  it  does  not  require  an  application 
of  arsenic  to  kill  them.  Thej  will  often  die  even  under  this  anti- 
septic paste,  but  when  protected  in  this  way  they  seldom  give  the 
slightest  discomfort  while  dying,  and  the  tooth  will  often  remain 
free  from  pain  till  it  is  shed.  In  other  cases  it  may  become  some- 
what sore  following  the  death  of  the  pulp,  and  even  end  in  a  small 
abscess  opening  on  the  gum;  but  there  is  never  the  intense  suffering 
and  excessive  swelling  which  sometimes  accompanies  teeth  that  are 
neglected  and  left  open  to  the  fluids  of  the  mouth. 

Treatment  of  Abscessed  Deciduous  Teeth. 

The  canals  should  be  as  carefully  cleaned  as  possible  by  mechani- 
cal means,  and  then  packed  with  cotton  saturated  with  oil  of  cloves. 
Some  unvulcanized  rubber  sufficient  in  size  to  fill  the  cavity  should 
then  be  forced  down  upon  the  cotton,  and  compression  made  on  the 
rubber  till  the  oil  of  cloves  comes  out  the  fistulous  opening  on  the 
gum.  When  this  is  accomplished,  if  the  preliminary  cleansing  has 
been  thorough  and  the  contents  of  the  canals  have  not  been  too 
offensive,  the  tooth  may  be  filled  at  the  same  sitting.  If  the  den- 
tine seems  saturated  with  foul  matter,  the  canals  should  be  packed 
with  cotton  and  oil  of  cloves  and  sealed  with  gutta-percha  for  a 
week.  If  the  fistula  still  remains  open  at  the  end  of  that  time,  it 
should  again  be  injected  with  oil  of  cloves  and  the  tooth  filled  in 
the  following  way :  The  pulj)-chamber  and  canals  should  be  flooded 
with  a  solution  of  gutta-percha  in  eucalyptol,  and  some  temporary 
stopping  slightly  warmed  should  be  forced  down  into  each  canal 
till  the  eucalyptol  solution  shows  at  the  opening  of  the  fistula.  The 
temporary  stopping  should  be  left  in  the  canals  as  a  root-filling, 
and  the  cavity  proper  may  then  be  filled  with  whatever  material  is 
indicated. 

Following  this  treatment,  these  cases  will  almost  invariably  heal 
and  give  no  further  trouble.  Indeed,  the  management  of  ab- 
scessed deciduous  teeth  is  usually  a  matter  of  not  much  difficulty, 
provided  the  patient  is  at  all  tractable  and  there  is  enough  of  the 
tooth  left  to  work  upon. 


THE    MAXAGEMEXT    OF    CHILDEEN's    TEETH.  275 

The  Management  of  Permanent  Teeth  in  Childhood. 

This  is  one  of  the  most  important  problems  in  the  entire  practice 
of  dentistry.  Decay  of  the  teeth  has  been  called  essentially  a  dis- 
ease of  yonth,  and  it  is  undoubtedly  trne  that  durina;  childhood  it 
seems  to  make  its  fiercest  attacks.  The  teeth  to  suffer  most  from 
its  ravages  are  accordingly  among  those  which  erupt  earliest,  and 
of  these  may  be  mentioned  particularly  the  first  permanent  molars. 
These  teeth  should  be  the  object  of  especial  care  on  the  part  of  the 
dentist.  Beyond  the  fact  that  they  are  called  upon  to  do  longer 
service  in  the  mouth  than  any  of  the  other  teeth,  they  have  an 
important  function  in  the  dental  arch  which  is  not  often  carefully 
enough  considered  by  practitioners.  This  relates  to  the  time  of 
their  eruption  and  to  the  position  they  occupy  in  the  arch.  To 
them  it  is  given  to  be  the  standard-bearers  of  the  jaws  during  that 
period  which  intervenes  between  the  loss  of  the  deciduous  molars 
and  the  growth  to  full  length  of  the  bicuspids  and  second  perma- 
nent molars.  Without  the  first  permanent  molars  in  their  proper 
position  at  this  time  the  jaws  are  allowed  to  drop  too  close  together, 
so  that  the  upper  incisors  overlap  the  lower  incisors  more  than  is 
normal,  and  the  bicuspids  and  second  molars  are  never  allowed  to 
assume  their  true  length  and  position.  This  matter  of  maintain- 
ing the  jaws  in  their  proper  relation  one  to  the  other  is  very  impor- 
tant, as  it  relates  to  the  symmetry  of  the  face  and  to  the  most  per- 
fect mastication,  and  every  effort  should  therefore  be  made  to 
preserve  the  first  permanent  molars  in  their  normal  length.  These 
teeth  should  l)e  watched  from  the  time  of  their  eruption,  and  on 
the  slightest  approach  of  caries  they  should  be  carefully  filled.  In 
case  the  patient  fails  to  apply  to  the  dentist  till  decay  has  so  in- 
volved the  teeth  that  they  are  badly  broken  down  and  not  capable 
of  maintaining  the  jaws  in  their  correct  position,  every  effort 
should  be  made  to  so  build  them  up  with  fillings  that  this  function 
be  not  lost,  and,  failing  in  this,  they  should  be  crowned  even  at  this 
early  age  rather  than  yield  them  up  to  the  forceps. 

The  choi<-('  of  materials  to  be  used  foi-  filling  these  teeth  in  the 
early  history  of  their  eruption  must  be  governed  largely  by  the 
ability  and  disposition  of  the  patient  to  withstand  dental  operations. 


276  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

If  decay  occurs  on  the  occlusal  surface  during  the  period  of  the- 
tooth's  eruption  through  the  gum,  as  is  sometimes  the  case,  the 
most  serviceable  material  to  check  the  disease  at  this  time  is  usually 
cement.  It  may  be  employed  with  less  thorough  preparation  of 
the  cavity  than  is  demanded  for  metal  fillings,  and  it  will  prove 
eif ective  as  a  temporary  expedient  to  tide  the  tooth  over  this  critical 
period  till  it  is  fully  erupted  and  in  a  condition  to  receive  a  more 
permanent  operation. 

This  material  may  be  used  in  the  very  earliest  stages  of  decay,, 
even  when  the  flap  of  gum  has  not  entirely  receded  from  the  oc- 
clusal surface;  and  in  some  mouths  where  the  tendency  to  decay 
seems  to  be  very  great  it  is  well  to  use  it  as  a  preventive  by  forcing- 
it  into  the  grooves  and  sulci  of  the  occlusal  surface  before  actual 
decay  has  begun. 

This  will  often  so  protect  the  surface  during  the  eruptive  period 
that  decay  will  be  avoided.  When  the  occlusal  surfaces  of  the 
teeth  of  the  two  jaws  so  approach  each  other  that  they  are  sub- 
jected to  the  friction  of  mastication  the  tendency  to  decay  is 
thereby  materially  lessened,  and  it  is  consequently  a  matter  of 
much  moment  to  prevent  decay  till  this  takes  place.  The  cement 
may  conveniently  be  forced  to  position  by  the  finger  of  the  opera- 
tor, as  was  advocated  in  the  treatment  of  deciduous  teeth,  and  con- 
siderable pressure  may  be  brought  to  bear  upon  the  filling-material, 
so  that  every  indentation  on  the  occlusal  surface  is  perfectly  filled. 
This,  while  it  may  not  be  considered  a  very  elegant  method  of 
operating,  is  assuredly  a  most  effective  one,  and  in  this  instance 
utility  is  paramount  to  elegance. 

In  cases  where  occlusal  cavities  have  been  filled  in  this  way  with' 
cement  the  teeth  should  be  examined  every  three  or  four  months, 
and  metal  fillings  inserted  as  soon  as  the  cement  wears  away  and 
the  conditions  in  the  mouth  make  it  possible  to  do  more  permanent 
work.  These  conditions  relate  to  expediency  of  operation  and  tO' 
the  increasing  fortitude  on  the  part  of  the  patient  to  withstand 
the  tedium  and  pain  necessary,  rather  than  to  any  pronounced 
change  of  structure  in  the  teeth.  That  a  change  does  take  place 
progressively  from  youth  to  age  is  without  question,  but  it  is- 


THE    MANAGEMENT    OF    CHILDKEN's    TEETH.  277 

neither  so  radical  nor  so  rapid  that  it  need  be  accounted  an  impor- 
tant factor  in  the  selection  of  a  filling-material.  Dr.  Black  has 
shown  conclusively  that  all  enamel  and  all  dentine  is  harder  at  any 
-age  than  any  of  our  filling-materials,  and  this  should  be  sufficient 
to  settle  the  question  so  far  as  it  has  a  bearing  on  the  choice  of  ma- 
1;erial.  If  tooth-tissue  is  found  which  is  softer  than  the  materials 
we  use  it  is  due  to  pathological  conditions  aside  from  dental  caries, 
and  need  not  be  considered  in  this  connection. 

As  to  the  choice  between  gold  and  amalgam,  this  should  be 
governed  by  two  considerations, — the  one  of  expense  and  the  one 
of  an  adequate  endurance  on  the  part  of  the  patient  to  submit  to 
gold  operations  without  undue  nervous  strain.  It  should  be  the 
aim  of  all  operators  who  take  pride  in  their  work,  and  who  wish  to 
•do  the  most  permanent  service,  w'hen  they  have  the  care  of  the 
teeth  from  childhood,  to  keep  amalgam  out  of  the  mouth  entirely, 
but  this  does  not  seem  in  all  cases  to  be  possible.  We  must  not 
jeopardize  the  nervous  system  of  our  young  patients  in  the  blind 
effort  to  live  up  to  some  high  ideal,  no  matter  how  beautiful  it  may 
appear  to  us.  !N"either  will  it  do  to  affirm  that  gold  should  never 
be  used  under  a  certain  age,  say  the  age  of  twelve,  as  we  have  so 
•often  heard.  It  is  not  a  question  of  age  at  all.  It  is  a  question 
of  temperament,  a  question  of  physical  and  mental  stamina  on  the 
part  of  the  patient.  Some  children  at  a  given  age  have  a  much 
greater  capacity  for  enduring  operations  upon  the  teeth  than  have 
other  children  at  the  same  age,  and  every  operator  should  make  a 
careful  study  of  this  matter  among  his  patients. 

A  very  useful  material  for  filling  these  occlusal  cavities  where 
the  area  of  the  cavity  is  not  too  great  is  a  combination  of  gold 
foil  and  tin  foil  rolled  together.  This  can  be  used  when  the  gold 
•operation  would  be  too  exhausting,  and  if  properly  manipulated  it 
will  prove  a  very  satisfactory  and  often  a  very  permanent  opera- 
tion. With  an  operator  who  is  familiar  with  its  manipulation  it 
may  be  inserted  so  rapidly  that  it  is  seldom  necessary  to  apply  the 
rubber  dam,  and  this  of  itself  is  often  an  important  item  in  the 
management  of  children's  teeth.  It  is  especially  indicated  in  oc- 
■clusal  cavities  of  upper  molars  and  bicuspids,  the  lower  molars 


278  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH. 

ordinarily  calling  for  fillings  too  great  in  area  to  make  tMs  mate- 
rial serviceable.  It  cannot  be  depended  upon  to  wear  well  in 
cavities  with  a  broad  masticating  surface. 

There  is  one  j)oint  upon  first  permanent  molars  which  calls  for 
the  most  careful  attention  in  the  early  period  of  their  eruption, — 
viz,  the  mesial  surface.  This  surface  is  in  contact  with  the  second 
deciduous  molar  for  several  years  before  the  loss  of  the  deciduous 
teeth,  and  if  the  tendency  to  decay  is  great  in  that  mouth,  or  if  the 
deciduous  molar  is  affected  on  its  distal  surface,  the  first  permanent 
molar  is  almost  certain  to  suffer.  It  is  well  in  many  of  these  cases, 
as  soon  as  the  permanent  tooth  is  fully  erupted,  to  grind  away  the 
distal  surface  of  the  deciduous  tooth  so  that  there  is  only  a  narrow 
contact  between  the  two.,  In  this  way  the  mesial  surface  of  the 
permanent  molar  is  more  readily  kept  clean. 

In  case  decay  occurs  on  this  surface,  it  may  ordinarily  best  be 
controlled  during  the  presence  of  the  deciduous  teeth  with  gutta- 
percha. If  a  sufficient  depth  of  cavity  cannot  be  gained  to  secure 
the  gutta-percha  in  place,  it  is  best  to  flow  cement  over  the  surface 
as  a  temporary  expedient,  though  cement  on  these  proximal  sur- 
faces must  not  be  depended  upon  for  any  length  of  service.  The 
patient  should  be  instructed  to  report  immediately  on  the  loss  of 
the  deciduous  molar,  and  whether  the  permanent  tooth  has  been 
filled  with  cement  or  gutta-percha  it  should  at  that  time  be  replaced 
with  gold.  This  can  be  done  to  better  advantage  before  the  erup- 
tion of  the  second  bicuspid,  when  the  mesial  surface  of  the  perma- 
nent molar  is  freely  presented  to  the  operator,  than  at  any  time 
subsequently.  At  this  sitting  every  vestige  of  affected  enamel 
should  be  included  in  the  cavity,  and  the  metallic  surface  be  made 
sufficiently  broad  to  render  the  operation  as  permanent  as  pos- 
sible; 

In  cases  where  the  proximal  surface  is  so  decayed  that  the  oc- 
clusal surface  becomes  involved  before  the  operator's  attention 
is  called  to  it,  the  best  temporary  filling  is  ordinarily  to  be  found  in. 
a  combination  of  gutta-percha  and  cement,  laying  gutta-percha, 
over  the  gingival  third  of  the  cavity  and  completing  the  filling  with, 
cement.     The  latter  will  probably  require  occasional  renewal,  but. 


THE    MANAGEMENT    OF    CHILDREn's    TEETH.  279 

the  gutta-percha  will  ordinarily  last  till  the  patient  is  in  a  condition 
to  have  gold  inserted. 

The  care  of  permanent  incisors  in  the  mouths  of  children  is  a 
matter  calling  for  careful  consideration.  If  decay  occurs  very 
early,  it  is  usually  best  to  resort  to  cement  or  gutta-percha,  instead 
of  attempting  permanent  work  at  the  outset.  The  choice  between 
gutta-percha  and  cement  must  be  governed  by  the  nature  of  the 
decay.  If  there  is  sufficient  penetration  to  securely  hold  the  gutta- 
percha in  place,  it  may  be  depended  on  for  more  permanent  work 
than  cement,  but  in  shallow  cavities,  too  sensitive  for  much  cutting, 
the  cement  may  be  maintained  in  place  more  readily  than  gutta- 
percha. Xeither  of  these  materials  need  be  considered  in  the  light 
of  anything  but  temi^orary  expedients,  and  the  patient  should  be 
carefully  studied  and  judiciously  schooled  toward  an  attitude  of 
sufficient  fortitude  to  submit  to  gold  operations  as  early  as  may 
seem  practicable.  The  date  at  which  gold  may  be  substituted  for 
tlie  other  materials  must  depend  on  the  sensitiveness  of  the  teeth 
and  the  ability  of  the  patient  to  submit  to  thorough  work  without 
too  much  nervous  tax.  It  is  folly  to  attempt  to  insert  gold  while 
the  patient  is  so  illy  under  control  that  perfect  work  is  impossible, 
as  it  is  also  wrong  to  defer  longer  than  necessary  the  insertion  of  a 
reliable  material  like  gold  and  leave  the  teeth  to  the  mercy  of  mate- 
rials long  since  proved  to  lack  permanence. 


INDEX. 


A 

PAGE 

Abscessed  teeth,  treatment  of. 258 

Amalgam  157 

Amalgam,  manipulation  of 227 

Amalgam,  method  of  packing 229 

Annealing  gold 165 

Appliances  for  examining  the  teeth..  45 
Application  of  the  dam  in  difficult 

cases 73 

Applying  the  dam  for  operations  on 

buccal,  labial,  or  lingual  cavities  .  72 
Arsenic,  destroying  the  pulp  with... 248 
Automatic  mallet,  the 177 

B 

Bicuspid-    and   molars,   cavities   in, 

102,  104,  181 
Bicuspids  and  molars,  clamps  for....  54 
Bicuspids    and    molars,    fillings  in, 

1%,  212 

Bleaching  teeth 268 

Buccal,  labial,  or  lingual  cavities 126 

Buccal,  labial,  or  lingual  cavities,  ap- 
plying the  dam  for  operations  on...  72 
Buccal,    labial,    or   lingual  cavities, 

clamps  for 56 

Buccal,  labial,  or  lingual  fillings 219 

Buccal,  labial,  or  lingual  fillings,  fin- 
ishing  220 

c 

Calculus,  salivary 1 1 

Calculus,  serumal 18 

Capping  pulps,  materials  for 244 

Capping  pulps,  method  of 240 

Care  of  the  teeth,  instructions  to  pa- 

ti'-nts  as  to 28 

Caries,  examination  of  the  teeth  for..  44 


PAGE 

Cavities,  classification  of. 79 

Cavity  preparation 81 

Cements 159 

Cements,  manipulation  of 231 

Cervical  clamps  for  buccal,  labial,  or 

lingual  cavities 56 

Children's  teeth,  the  management  of.. 269 

Clamps,  kinds  of. 54 

Classification  and  preparation  of  cav- 
ities    79 

Cocaine,  removal  of  the  pulp  with. ...251 

Cohesive  and  non-cohesive  gold 164 

Crystal  golds 172 

D 

Deciduous  teeth,  management  of  the. 269 
Deciduous   teeth,   treatment    of  ab- 
scessed  274 

Deciduous  teeth,  treatment  of  ex- 
posed pulps  in 273 

Dental  caries '^1 

Dentine,  hypersensitive 142 

Deposits  on  the  teeth ^ 

Deposits  on  the  teeth,  kinds  of. 11 

Destroying  the  pulp  with  arsenic 248 

Destruction  of  the  pulp 247 

Detail  of  cavity  formation  in  proxi- 
mal cavities  in  anterior  teeth  in- 
volving the  incisal  angle 97 

Detail  of  cavity  formation  in  proxi- 
mo-occlusal   cavities   in   bicuspids 

and  molars '  '7 

Detail  of  cavity  formation  in  simple 
proximal  cavities  in   incisore  and 

cuspids °' 

Diflerent  forms  of  gold 170 

Disto-occlusal    fillings   in    bicuspids 

and  molars , 203 

281 


282 


INDEX. 


E 

PAGE 

Examination  of  the  teeth  for  caries...  44 
Examining  the  teeth,  appliances  for..  45 
Exclusion  of  moisture  during  opera- 
tions   47 

F 

Filled  teeth,  opening  into  where  the 
pulps  have  died  but  lain  dormant..2fi6 

Filling-materials 150 

Filling  pulp-canals 254 

Finishing  buccal,   labial,  or  lingual 

fillings 220 

Finishing  gold  fillings  on  the  occlu- 
sal surfaces  of  bicuspids  and  molars.  21 8 
Finishing  proxirao-occlusal  fillings  in 
bicuspids  and  molars 209 

G 

Gold 164 

Gold,  annealing 165 

Gold  and  its  combinations 150 

Gold  and  iridium 156 

Gold  and  platinum 154 

Gold  and  tin 155 

Gold,  cohesive  and  non-cohesive 164 

Gold  fillings,  the  introduction,  con- 
densation, and  finishing  of. 185 

Gold  inlays 239 

Gutta-percha 160 

Gutta-percha,  manipulation  of. 234 

H 

Hand  mallet,  the ...174 

Hand  pressure 18(i 

Hypersensitive  dentine 142 

I 

Inlay  fillings,  making. 235 

Inlays 161 

Inlays,  gold 239 

Inlays,  porcelain 235 

Instructions  to  patients  as  to  the  care 
of  the  teeth 28 


PAGE 

Instruments  for  the  removal  of  sali- 
vary calculus 19 

Interproximal  space,  the 110 

K 

Kinds  of  clamps 54 

Kinds  of  deposits 11 

Kinds  of  rubber  dam 49 

L 

Ligatures 58 

M 

Making  inlay  fillings 235 

Mallets  and  malleting 174 

Management  of  children's  teeth,  the.. 269 
Management  of  permanent  teeth  in 

childhood,  the 275 

Management  of  pulpless  teeth  in  the 
anterior  part  of  the  mouth  to  pre- 
vent discoloration,  the ..267 

Manipulation  of  amalgam 227 

Manipulation  of  cements 231 

Manipulation  of  platinum  and  gold 

in  filling  teeth 221 

Manipulation  of  tin  and  gold 223 

Manner  of  applying  the  dam  in  the 

ditferent  locations  in  the  mouth 64 

Manner  of  using  the  matrix 201 

Materials  for  capping  pulps 244 

Matrix,  the 196 

Matrix,  manner  of  using  the 201 

Method  of  capping  pulps 246 

Method  of  packing  amalgam 229 

Moisture,  exclusion  of,  during  opera- 
tions   47 

Napkins 77 

o 

Occlusal  cavities  in  bicuspids  and 
molars 131 

Occlusal  fillings  in  bicuspids  and 
molars 212 


INDEX. 


283 


PAGE 

Occlusal  fillings  in  bicuspids  and 
molars,  finishing 218 

Opening  into  filled  teeth  in  which  the 
pulps  have  died,  but  have  lain  dor- 
mant   266 

P 

Peridental  membrane,  protection  to, 

in  malleting 182 

Platinum  and  gold,  manipulation  of.22 1 

Pluggers 190,  207 

Porcelain  inlaj-s 23'"> 

Proximal   cavities   in   anterior  teeth 

involving  the  incisal  angle 96 

Proximal  cavities  in  incisors  and  cus- 
pids, simple 81 

Proximal   cavities  in  bicuspids  and 

molars 102 

Proximal  fillings  in  anterior  teeth  in- 
volving the  incisal  angle 194 

Proximal   gold   fillings   in   incisors, 

simple 186 

Proximo-occlusal  cavities  in  bicus- 
pids and  molars 104 

Proximo-occlusal  fillings  in  bicuspids 

and  molars 196 

Proximo-occlusal  fillings  in  bicuspids 

and  molai-s,  finishing 209 

Pulp-canals,  filling  254 

Pulp-capping  241 

Pulp,  destruction  of  the 247 

Pulp,  removal  of  the 2")2 

Pulpless  teeth,  treatment  of. 2'»8 

R 

Pvapid  mallets 178 

Removal  of  calculus,  instruments  for.   1 9 

Removal  of  salivary  calculus 17 

Removal  of  serumal  calculus 2;^ 

Removal  of  stains  from  the  teeth 26 

Removal  of  the  pulp 2r)2 

Removing  the  pulp  with  cocaine 251 

Rolls,  cotton 79 

Riil)ber-dam  flamps '>'! 

Rubber  dam,  kinds  of. 49 

Rubber  dam,  method  of  applying  in 
different  locutions  in  the  moutli....  64 


PAGE 

Rubber  dam,  punching  the  holes  in..  51 

s 

Salivary  calculus 11 

Salivary  calculus,  removal  of. 17 

Sensitive  dentine,  treatment  of. 138 

Separating  teeth 84,  115 

Serumal  calculus 13 

Serumal  calculus,  removal  of 23 

Simple  proximal  cavities  in  bicuspids 

and  molars 102 

Simple  proximal  cavities  in  incisors 

and  cuspids 81 

Simple  proximal  gold  fillings  in  in- 
cisors  186 

Size  of  rubber  dam 50 

Stains  on  the  teeth 15 

Stains  on  the  teeth,  removal  of 26 

T 

Technique  of  removing  salivary  cal- 
culus    20 

The  automatic  mallet 177 

The  hand  mallet 174 

The  interproximal  space 110 

The  introduction,  condensation,  and 
finishing  of  gold  fillings  in  the  dif- 
ferent classes  of  cavities 185 

The  treatment  of  pulpless  teeth 258 

The  use  of  napkins  and  cotton  rolls 
for    maintaining    dryness    during 

operations 77 

Tin 159 

Tin  and  gold,  manipulation  of. 223 

Treatment    of    abscpssed    deciduous 

teeth 274 

Treatment  of  abscessed  teeth 258 

Treatment  of  exposed  pulps  in  decid- 
uous teeth 273 

Treatment  of  pulpless  teeth  having 

a  fistulous  opening  on  the  gum 264 

Treatment  of  pulpless  teeth  where  the 
canals  have  been  long  exjwsed  to 
the  fluids  of  the  mouth,  but  where 

there  is  no  fistulous  opening 258 

Treatment  of  sensitive  dentine  in 
deep-seated  cavities 138 


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